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K)2) 

IQ60 



THIS VOLUME IS DEDICATED 



TO THB 



(iohrnors of $1 Park's hospital, Joitban, 



WHO) BT ESTABUSHINa ATJRAL SURGERY AS A DISTINCT DEPARTMENT 
OF STUDY IN THEIR HOSPITAL AND MEDICAL SCHOOL, 

EVINCED A DESIRE TO 
ELEVATE THE SUBJECT OF DISEASES OF THE EAR TO ITS DUE POSITION, 

AS A BRANCH OF PROFESSIONAL KNOWLEDGE 
BASED UPON CLINICAL OBSERVATION AND SCIENTIFIC RESEARCH. 



P R E F A C F,. 



In preparing the present work, it has been my aim to 
produce a practical treatise on the Diseases of the Ear, 
having for its foundation the anatomy, physiology, and 
pathology of the organ. This volume, however, does not 
profess to gi\'e a complete description of the structure and 
functions of the Ear : it will be perceived that the domains 
of anatomy and physiology have only been entered upon 
when requisite for the elucidation of the pathology or treat- 
ment. 

And now, after twenty years' labor, seeing tliis volume 
complete, I cannot but regret that it is not more worthy of 
its subject, and of the intelligence of the Medical Profes- 
sion, to which it is addressed. It only remains for me to 
continue to devote myself to my labors. And thus, while I 
sincerely thank the nmnerous members of the Profession for 
their generous assistance, in supplying me with the larger 
part of the meaus of research which I have enjoyed, I beg 
still further to solicit their aid. Long engaged upon another 
work, in the shape of " lUustratious of the Pathology of the 
Ear," for which I possess a large amount of material, I 
nevertheless require much more. Indeed, even since this 



Vm PREFACE. 

volume has been passing through the press, two recent spe- 
cimens, received from medical men in the country, have 
elucidated two entire series of preparations in my Museum.* 

I need scarcely draw attention to the beautifrd illustra- 
tions in this volume, which, with two or three exceptions, 
were drawn from nature, on wood, by Mr. Ford. 

Few references having been made in the body of this 
volume, to the investigations on which it is foimded, I have 
given, in an Appendix, a list of my published papers, to- 
gether with their dates, so that the reader may refer to them 
when he thinks it desirable to do so. 

' It alwajs affords me much pleasure to show my Museum to medical men. 
18 Sayilb Row, January 20, 1860. 




CHAPTER L 

INTRODUCTION. 

Neglect of the sttidj of tlie morbid nnntomy of the cur, ihs cauae of our igoo- 
nince of aural surgery — Mode of investigaUng the diseases of the ear 
— Method of dissecting the ear, 



CHAPTER II. 

THE EXTERNAL EAR. 

Anatomical observations — Use of the external ear — Effect of Iha removal of 
the external ear (cast;) — Pathological observations — Malformalions of the 
external ear, with abdtnce of the external meatus (cases) — Supurnu- 
merary ears — Inflammatory diseases — Chronic erysipelas — Chronic ec- 
lemt— Cysts — Tumors — Deposits— Malignant disease, .... 



CHAPTER III. 

THE EXTERNAL MEATUS. 



Analoroical obacrvations — Osseous meatus — Membranous meatus — Objec 
in exploring the mealus^ — Means of exploration — Lamps— Speculum- 
Mode of exploration, 



CHAPTER IV. 
THE EXTERNAL MEATUS {conlinutd). 



Foreipi bodies in the meatus — Mode of removal— Cases — Ceruminous friands 
— Their diseflses — Accumulations of cerumen — Their causes — Table of 
two hundred ciwes in which cerumen was removed — Symptoms — Effects 
— Treatment — Mode of removal — The syringe and its nse — Cases, 



CONTEKTS. 



CHAPTER V. 
THE EXTERNAL MEATUS {eotttinvtd). 



1. Acute inflanimaliaQ ; — a, Acute inflammatioD conSned lo the dermis— 
Trealment — Cases. (, Acute inflBmmtlion cxtenillng to the brain aii' 
its membranes — Treatment — Ciuea. 
!. Chronic inflanimatian : a, Chronic inflammation with hjrpertroplij and at 
cumalation of epidermia — Treatment — Cases, b, Chronic catarrhal in 
BammatioD — Treatment — Cases, c, Chronic catarrhal inftammatiur 
extending to the bone and lo tlic brain — Treatment — Cases, d, Ulcere 



CHAPTER VI. 

THE EXTERNAL MEATUS {rontinued). 



Causes of polypus — Sjmptoms — Three species of polvpus : 1. The cellultr i 

raspberry polypus — Stroelure — Treatment with polnsaa cum calce — .1 

Casei — Treatment by removal with the lerer-ring forceps — Cases. 2. if 

The fibro-gelftlinoun polypus — Structure — Treattnent — Cases. 3. The J 
globular cellolar polypus^^lruclure — Treatment — Cases, . .11 



CHAPTER VII. 

THE EXTERNAL MEATUS {conclude,!). 



Oueous tumor* — Structure — Two classes — Trealment — Casus — Mollua 
tumors — Structure — Effects on the bone — Treatmenl — Case — Condi 
of the subject of the diseMes of the eitcrual meatus — Tabular vi< 
the morbid conditions found in the- meatus cKteroug in 1013 dissections, 



CHAPTER VIII. 
THE MEMBttANA TYMPANI. 



of 




J roKiTiosa. 



The epidermoid layer — The dermoid layer — The fibrous layers . — The radiate 
fibrous layer — Thecircutarfibrouslmyi-r — The mucous layer — Tensor liga- 
m«nt — KuDclioni of the membrknt tjmpaui, 



CONTENTS. 



CHAPTER IX. 

THE MEMBaANA TYMPANI (eonlinued). 

The epid«rmoid iajer — Dermoid Injer — a, Acute inflammation— Treatment — 
Cases. 6, Chronic ioflaramfttloii — Civtea. c, Ulceration — Caaes. Fibrous 
I&minm: a, Acnte iaIlanimatLan. b, Cbronic inflBDicanlioii. c, Ulceration. 
d, Calcareous degeneration, t, Relaxaliiin of the membrana Ijmpani — 
Treatment — Cases, 



CUAPTER X. 

THE MEMBRANA TYMPANI (concluded). 

Perforation, causes — Phjaiological observations — Experiments previous to 
the fortnation of aa arliGcial membrana tjmpani — On the artificial 
membroaa timpani — The mode of appSjiog it — Cases — Rupture of ibe 
membrana tjmpuui — Ph^aiulogical observations — Pathological observa- 
tions — Cases, .... ..,.,.. 



CHAPTER XI. 

THE EUSTACHIAN TUBE. 

Anatomical observatious — Phjsiological observations — Pathological observa- 
tions — Seat of obstruction ia the Eustachian tube. — 1, The faucial ori- 
fice. 2, The tympanic orifice. 3, Middle part. — Causes of obstruction : 
— I, Thickened mucous membrane. 2, Relaxed mucous memhraue. a, 
Obstructioo of the faucial orifice from thickened mucous membrane — 
The exploration of Ibe lube— The otoscope — Treatment— Use of tlie 
Eustachian catheter and of the explorer — The excision of the tonsils- 
Coses, b, Obstruction of the Eustachian tube at its faucial orifice from 
relaxed mucous membrane — Symptoms — Treatment — Cases- c, Obstrnc* 
lion ofthe Eustachian tube at the lympaaic orifice from thickened mucons 
membrane — Symptoms — Treatment — On the operation of puncturing the 
membrana tympani, d, Obstruction of the middle part of the Eustachian 
tabe by mucus, by stricture, or by membranous bands, ....', 



CHAPTER XII. 

THE CAVITY OF THE TYMPANUM. 

Anatomical observations — Pathological observations — Diseases of ibe mucous 
membrane : — a. Congestion, b, Acute inflammation — AHectlng the 
portio dura nerve — Estcnding to the brain — Scrofulous matter in the 
tympanic cavity, e, Chronic inllaniinaliun. d, Chronic catarrhal inflam- 
maljon, e, Chronic catarrhal inflammation extending to the bone, dura 
mater, or brain. ^ Ulceration of the mucous membrane. 



CONTEKTS. 



CHAPTER XIII. 

THE CAVITY OF THE TYMPANUM {eoneluded). 

I, Rigiditj of the mucoua membrane — ^Cause of deafneaa in advancing jcara — 
Treatment — Coses, b, The formation of banJa of adhcaioii. c, Ancbj- 
loaia of Iha atapa to the fenestra ovalia — Pathological obaer»'al[oD8 — 
Treatment — Cosea. d, Diaconnection of the incns and stapes — Phjaiolo- 
gical observationa — Pathological observationa — CaaeB, .... 



CHAPTER XIV. 



THE MASTOID CELLS, 



Analomicttl observations — a, Diaeaees of the mastoid colls in childhood — 
Cases of the diaeaae advancing lo ihe- bone and the cerebrum. Ii, Diseaaes 
of the maatoid cells in the adult — Acute ioflammutioo of the mucons 



membrane — Chronic inHammation of the muc 
infection — Symptoms of remittent fever — Cari 
Abscess in the cerebellum, e, Necrosis of then 
of the portio dnra nerve — Treatment — Oplnlor 
in cases of discharge from the ear, 



lus membrane — Purulent 
a of the lateral sulcua — 
astoid process — Paralysis 
respecting life ins 



CHAPTER XV. 

THE DISEASES OF THE NERVOUS APPARATUS OP THE EAR, 
PRODUCING WHAT IS USUALLY CALLED "NERVOUS DEAF- 
NESS." 

a. Diseases in which the ear alone is affected : — \. From concussion — Three 
modes — Blows on the ear — Loud sounds — Falls. 2. From the applica- 
tion of cold — Cold air — Cold water. 3. From the effect of morbid poi- 
sons — Rheumatic fever — Tjphns fever — Scarlet fever — Humps — Gont. 

/y. Diseases in which the brain, aa well as the ear, is affected : — 1. Mental 
excitement — Over-study — Sorrow. 2. Bodily Debility — Want of sleep 
— Accouchements — Over-eibauslion in hot climates — Fasting — Nen- 
ralgia, 36T 



I 



CHAPTER XVI. 

THE DISEASES OF THE NERVOUS APPARATUS (concluded), 
ecrosis of the petrous 




1 



CONTENTS. xm 



CHAPTER XVII. 

MALIGNANT DISEASE OF THE EAR. 

PA0E 

Origin in the mucous membrane of the tympanum — Destruction of the 
petrous bone — Sometimes mistaken for polypus — Operations to be avoided 
— ^Brain and dura mater involved — Treatment, 404 



CHAPTER XVIII. 

ON THE DEAF AND DUMB. 

Diseases producing deaf-mutism — The condition of the ears in the deaf and 
dumb| as ascertained by examination during life — The condition of the 
ear in the deaf and dumb, as revealed by dissection — ^The mode of exami- 
ning a child supposed to be deaf and dumb— On the medical treatment of 
the ears of the deaf and dumb — The amount of hearing possessed by chil- 
dren usually accounted deaf and dumb — On the education of the deaf and 
damb| with cases, 413 



CHAPTER XIX. 

EAB-TBUMPET8 AND THEIR USE, 435 



APPENDIX. 

List of published papers on the Structure, Functions, and Diseases of the 
Ear, 437 



LIST OF ILLUSTRATIONS. 



FIO. PAOB 

1. Catting Forceps, 40 

2. Malformed right External Ear of a child, 47 

3. The rndimentary Meataa Auditorius Eztemns of a child, in the form of a fissure 

posterior to the Condjloid Process 48 

4. The Tympanic Cavitj, with the Eustachian tube opening into its anterior and 

inferior part, 49 

5. Rudimentary External Ears, . 50 

6. Hssmatooele of the External Ear (Wilde), 54 

7. Tumor of the Lobule (Wilde), 55 

8. A vertical section of the left Meatus Eztemus, from without inwards, . 57 

9. The Orifice of the Meatus Extemus, showing its oral shape, .... 59 

10. The Osseous Meatus Extemus of an infant, 60 

11. The mode of examining the Ear by aid of Sunlight, ...... 62 

12. Miller's Lamp, open, 63 

13. Miller's Lamp, closed, 63 

14. A set of Specula for the purpose of examining the External Meatus, 65 

15. The Surgeon examining the External Meatus by means of Miller's Lamp and 

the Tubular Speculum, 66 

16. Rectangular Forceps, 72 

17. The External Meatus greatly dilated by a piece of cotton-wool, ... 78 

18. Cerumen in contact with the outer surface of the Membrana Tympani, 80 

19. Meatus greatly dilated by cerumen, 81 

20. Anterior wall of the Osseous Meatus partly absorbed, following the pressure of 

an accumulation of cerumen, 81 

21. Cerumen projecting through the Membrana Tympani into the Tympanic Cavity, 82 

22. Syringe and Noxsle • . . 83 

23. Ear-spout, fitted on the head, 84 

24. Epidermis from the External Meatus in the form of a tubular cul-de-sac, and a 

layer arranged circularly, 97 

25. The Internal Surface of the Temporal Bone, showing two orifices in the Lateral 

Sinus, filled by cerumen ; and also the carious Sulcus Lateralis, . .105 

26. The External Surface of the Temporal Bone, showing a carious portion extend- 

ing from the Mastoid Process to the root of the Zygomatic Process, .106 

27. Raspberry Cellular Polypus, 112 

28. Cellular structure of the Raspberry Polypus, 113 

29. A large Raspberry Polypus, visible at the orifice of the Meatus, . . 113 

30. The Snare of Mr. Wilde, 119 

31. The Lever-ring Forceps, open, . .119 

32. The Lever-ring Forceps holding a Polypus, 121 

33. Fibro-gelatinous Polypus, 123 



LIST OP ILLUSTRATIONS. 



34. Strootur* of lb« Fibro-gcUtinoai PolTpus, 

36. Th« Ring Poroapa 

38. Qlobulor Cellulu Poljpua - . . : 

37. Two Os>eoiu Tuaion prujicting riDin the iralls of Ifae Mentnii Eitcnm«, . 

38. The TertlcHl eection ot tbs Eiternnl Meatus and O»ieoue Tumor, 
30. Thn* Oueoui Tumort projeotiag from Ibe wallt nf Iha HsUnii, 

40. A large Oneona Tumor and two Emaller ones in ihe Mealna EilcrsOB, 

41. Two Oueoug Tumors at Ihe Eiternal Meataii in contact iatemally, . 
41. An Oneong Tumor growing from tba Upper Walt at the Meatus, 

43. Oneona Matter derelopei] rrooi the vaUe of the MeatDB Bilernni, 

44. Mollnscoui Tumor filling the whole uf tbe Meatus Exlcmoa, .... 

45. Oavitj in Che Meatus Eitemaa from which a Mailasooai tumor has been lemOTed, 
48. Aportnrei in the upper wall of the Meatus Eilarous com muni Dating with the 

Cerebral Tavilj, proJup«J by a MoUuMoua Tumor 

47. The Triangular Shining Spot at the anterior and inferior part of the aurfaoe of 

the Merabrana Tympani 

48. The Dermoid Layer of Ibc Membrann Tjmponi continnont with the Dermis lining 

theupper wall of the Meatus Eilamun 

49. The Radiate FibrouiLajer of the MemhranaTjmpaai 

BO. The Fibres composing the Radiate Fibrous Lamina (magnified), 

H, The Radiate Fibrous Lamina 

GS. The Kadlale FibrDa<i Lamina, alter having been treated with Aeelio Acid, 

63. Tbe CirfUlar Cartilaginous Band, alter having been treaUd b; Acetic Acid, 
M. Tbe Eiterniil Surface of tbe Circular Fibruns Lamina (eligbtl; magmfir'd). 
£9. Tbe Internal Sorfaoe of Ihe Ciranlar Fibrous Lamina (slightly magnifled), 

M. The Fibres composing the Circular Pihrous Lamina. 

&T. The Fibres of the Clrontar Fibrous Lamina, treated with Acetic Acid, 

58. The Radiate Fibrous Lamina, the Circular Fibruus Lamiua, and the Mucous 

Membrane of the MembranaTympani (slightly magnified). .... 

59. The Attachments of tbe TeD»or Tympanl Llgsment (slightly magniged), . 
AD. Epideminld Layer of the Memhrana Tympuni hypertrophied (magnifled), . 

61. Oianulations on the surface of the Dermoid Layer of the Membmna Tymp»ni, . 

A2. The Memhrana Tympani fallen in towards the Promontory (seen in section), . 

S3. Tbe Membrann Tympani fallen in towards Ihe Promontory {«een from without). 

64. Ap Orifice in the Membrana Tympani produeed by ulceration of the Fibrous 

63. Tbe Fibrous Layers of the Memhrana Tympani nicerated over a small oitent at 

AC. Calcareous Deposit in the Ciranlar Fibrous Lamina of tbe Membrana Tympani, 

67. Calcareous Deposit in the Radiate Fibrous Lamina of the Hembrana Tympani, 

65. The whole of tbe Membrana Tympani converted into Calcareous Matter, . 

A9. The ArUflcial Hembrana Tympuii, 

TO. Margin of the oirenmfsrence of the Homhrana Tympani remaining after the 

deslrnclion ofthe rest of the membrane, 

71, Handleof the Malleus remaining after tbe destruction of the Membrana Tympani, 

78. Body of Malleus remaining after destruction of Membrana Tymfani, 

73. Surgeon introducing the ArtlQciBl Membrana Tympani 

74. An Aperture in the lower part of the left Membrana Tympani, from rupture, . 

75. An Aperture in the posterior part of the right MembranaTympani, IVom rupture, . 
7S. An Aperture in tbe right Membrana Tympani 

77. ThoOloioopo. 

78. The Surgeon using the Otoscope, 

79. Tbe Explorer, and the Bnataohian Catheter into which it fiU, . . . . ; 



XVl LIST OF ILLUSTRATIONS. 

no. PAGE 

80. The Sargeon using the Euataohian Catheter and the Explorer, .... 228 

81. Striotare of the Eustachian Tube 247 

82. An antero-posterior vertical section of the Temporal Bone through the Tympa- 

nic Cayity and Mastoid Cells, 249 

83. The upper Osseous Wall of the Tympanum defective, . . . . 250 

84. The Canal for the Portio Dura Nerve at the upper part of the Tympanic Cavity 

incomplete, 260 

85. The Internal Surface of the Temporal Bone, the Tympanic Cavity diseased, . 283 

86. The lower Osseous Wall of the Tympanum incomplete, 286 

87. The Orifice seen from the Jugular Fossa, 286 

88. Membranous Bands connecting the Ossicles, 295 

89. Membranous Bands connecting the Ossicles to the Promontory (magnified), . 296 

90. The whole of the Circumference of the base of the Stapes anchylosed to the 

Fenestra Ovalis, the Crura detached, 299 

91. Base of the Stapes expanded, and osseous matter thrown around it and the Crura, 299 

92. Expansion of the base of the Stapes, and its protrusion into the cavity of the 

Vestibule (magnified), 300 

93. Expansion of the Vestibular Surface of the Articulation (magnified), 300 

94. The External Surface of the Temporal Bone of a child, 322 

95. A Vertical Section of the Temporal Bone of a child through the horizontal por- 

tion of the Mastoid Cells, 323 

96. The External Surface of the Temporal Bone, showing the irregular-shaped carious 

portion of bone above the Meatus, 326 

97. A Vertical Section of the Diseased Bone, . 327 

98. The right Petrous Bone, showing the carious condition of the Sulcus Lateralis, 346 

99. Caries of the External Semicircular Canal, 398 

100. Carious Temporal Bone, 409 



THE DISEASES OF THE EAR 



CHAPTER I. 

INTRODUCTION. 

NEGLECT OF THE 8TUDT OF THE MORBID ANATOMY OF THE EAR, THE CAUSE OF OUR 
IGNORANCE OF AURAL SURGERY — MODE OF INVESTIGATING THE DISEASES OF THE 
EAR — METHOD OF DISSECTING THE EAR. 

As introductory to this work on the Diseases of the Ear, I may be 
pardoned the observation, that the subject has hitherto been too 
much regarded, by the great mass of the profession, as a blank in 
Medical Science ; indeed, to quote from Mr. Wilde's introduction 
to his valuable treatise on Aural Surgery, medical men are too 
ready to affirm that " they know nothing about the diseases of the 
organ of hearing ;'* and many, looking upon the diflficulties that 
surround the investigation as insurmountable, have tacitly aban- 
doned its pursuit. Yet, if we carefully survey the history of the 
rise and progress of Aural, as a distinct branch of Scientific Sur- 
gery, one main cause pf the disrepute into which it had fallen may 
be traced to the neglect of the pathology of the organ of hearing — 
a neglect that doubtless led also to the ignorance which has pre- 
vailed as to the structure and functions of some of the most impor- 
tant of its parts. 

It is a question, however, whether the inherent diflficulties of 

Aural Surgery are of a nature to prevent its being as thoroughly 

lyiderstood as the other branches of surgery. This question has 

been answered in the affirmative by some, on the ground of the deep 

and hidden situation of the larger part of the organ, and the extreme 

3 



34 THE DISEASES OF THE EAR. 

intricacy of its structure. But surely the organ of hearing is not 
so much concealed from view as several others (the heart, for in- 
stance), of whose diseases we have a very clear knowledge ; nor is 
its structure more complicated than that of the eye. The result of 
my own experience, and I think also of those who have carefully 
attended to my practice at St. Mary's Hospital, is, that the diseases 
of the ear are not more diflBcult to diagnose, nor are they on the 
whole less amenable to treatment, than those of the eye, the joints, 
or almost any other organ that can be named. 

When my attention was first turned to the study of the diseases of 
the ear, I resolved to prosecute researches into the pathology of 
the* organ. From that time to the present, I have made nearly 2000 
dissections ; and although it must be manifest that this number is 
small, compared to that which is required for the thorough elucida- 
tion of the subject, still I feel it is a sufficiently solid foundation 
upon which to build a rational system of Aural Surgery. 

Fully aware of the difficulties in the way of procuring specimens 
from those deaf persons who had been inspected during life, and 
whose histories had been recorded, I determined at once to dissect 
every ear that I could obtain, in order to ascertain what are the 
most common morbid conditions to which the organ of hearing is 
subject ; in fact, to secure one step first, by ascertaining something 
of the morbid anatomy of the ear, before advancing to a consideration 
of its pathology. The result of my investigations established this 
general fact, that the existence of some of the most important affec- 
tions of the ear had not even been imagined. Having advanced 
thus far with the morbid anatomy of the ear, my next step was to 
pursue its pathology. This was effected, in the first place, by prose- 
cuting inquiries into the history of the patients whose ears were 
found to be diseased ; secondly, by dissecting the ears of deaf per- 
sons supplied to me by medical men, and comparing the morbid 
appearances observed with the notes accompanying the cases ; and 
thirdly, by availing myself of the opportunity, during some years, 
of inspecting all the deaf persons in an institution containing more 
than 2000 individuals, of recording their cases, and then of making 
dissections of the organ of hearing in those who died. By these 
means, and by the facilities offered at the public institutions to which 
I have been attached, of conducting post-mortem inspections of the 
patients attended by me, I have been able in many cases to compare 
the symptoms occurring during life, the appearances of the organ. 



INTBODUCTIOX. 



35 



and the history of the case, with the morbid structures found after 
deatli. 

Mode of inveatigatitiff the Diaeaaet of the Ear. — The following 
plan for eliciting all the important particulars wilh which a surgeon 
ought to be acquainted when endeavoring to form a diagnosis of dis- 
ease of the car, has been pursued by me during many years. Its 
use involves no great time or.labor ; and as it is desirable that it 
should be observed by those studying the subject, I will describe it 
in detail. 

I. The age and occupation of patient. 
II, State of health, temperament, condition of pulse, &c. 

III, If any relations are deaf, name them. 

IV. History of the affection ; duration ; supposed cause. Former 
st/viptonis : if at any time pain in the ears or head. Nature of pro- 
gre»s : whether rapid or slow ; if it has increased by sudden parox- 
ysms, or by imperceptible degrees. Present aymptoma : if pain, 
noises, or discharge ; amount of hearing power as shown by conver- 
sation ; whether the patient require to be spoken to distinctly in n 
room, or within the distance of a yard, or close to the ear : which 
ear is the worse. Causes aggravating the deafness : a cold, cold or 
moist weather, bodily fatigue or mental excitement, the act of mas- 
tication. Causes producing improvement: improved hcalih, dry 
air, a cold, cold weather, warm weather. 

V. Result of examination. 

Right ear. The distance at which the watch is heard.' 

Meatus : quantity and condition of the cerumen ; stale of the 
dermis and of the osseous wall. 

Membrana tympani : surface dull or shining, transparent or 
opaqiue, state of the triangular bright spot , if more or less concave 
than natural. 

Eustachian tube : if air is heard by means of the otoscope to enter 
the tympanic cavity naturally during deglutition, the nose and moutli 
being closed ; if the air is heard to enter the tympanic cavity natu- 
rally during a forcible attempt at expiration with the nose and mouth 
held closed. 

Left ear : ditto. State of mucous membrane of the fauces. 



Dediokl mui ibDnld woerUun Ibo il 
'hune bearing power is snppoaeit |i 



ruincs at irhloh fale WBtoh U ujunll}- lii 
be jierrnot. Th« hetrlng diitiiMe w 
ibnuld be gndumllf bronght lovirds 






36 THE DISEASES OF THE EAR. 

VI. Previous treatment. 

VII. Diagnosis. 

Although this enumeration of all the points which require filling 
up, might lead to the idea that the use gf this plan must be attended 
with considerable trouble in actual practice, it will be found other- 
wise, as numerous abbreviations may be resorted to. For example, 
take the following case. 

F. R., get. 43, architect. H. (health) : tolerable, but subject to 
attacks of sore throat. R. D. (relations who are deaf) : A brother 
and sister were both deaf when young, but quite recovered before 
reaching the age of 20. 

H. (history) : When a boy, suffered from ear-ache, which was 
often followed by deafness and sometimes by discharge from each 
ear. Subsequently the attacks of car-ache ceased ; but he has ever 
since been subject to fits of deafness which have usually come on 
during an attack of cold, and have lasted for periods varying from 
two to several weeks. During the attacks, the power of hearing has 
been so much diminished, that he could only hear a loud voice when 
within the distance of half a yard. Each attack has usually disap- 
peared with the occurrence of a sudden crack in the ear. The pre- 
sent attack came on six months ago, after a bad cold ; it has been 
slightly relieved on one or two occasions, but the deafness speedily 
returned. At the present time he requires to be spoken to in a loud 
voice within a yard of the cars, and there is a constant singing with 
a sensation of pressure in them, and a feeling as of weight on the 
head. P. T. (previous treatment) : The application of glycerine to 
the meatus ; syringing with warm water ; blisters behind the ears ; 
the use of the Eustachian catheter and a pump over the ears, all 
without benefit. R. E. (right ear) : M. E. (meatus externus) con- 
tained cerumen in a normal quantity and consistence. M. T. (mem- 
brana tympani) : Outer surface glassy ; the bright spot more elon- 
gated than natural, and somewhat striated ; the membrane of a 
leaden hue, and much more concave than natural. E. T. (Eusta- 
chian tube) : No air is heard to enter either during the act of swal- 
lowing or during a forcible expiration with closed mouth and nose, 
neither does the patient feel any sensation in the ears, nor is the 
membrana tympani seen to move during these operations. H. D. 
(hearing distance) : Contact. L. E. (left ear) : the same as the right, 
except that the membrana tympani is somewhat opaque. The watch 
is only heard when pressed upon the ear. 



INTRODUCTION. 37 

The mucous membrane of the fauces is red and spongy, and much 
thicker than natural; and each tonsil is somewhat enlurged. 

D. (diagnosis) : Occlusion of the faucial orifice of each Eustachian 
tuhe by thickened mucous membrane. The grounds for foi-ming this 
diagnosis are : — 

Firstly. The history of the case, the constitution of the patient, 
the peculiar similar attacks which had occurred to a brother and 
sister, and especially the sudden attacks of deafness following a 
cold, and their sudden disappearance after a crack, the latter being 
causeil by the sudden entrance of the air into the tympanic cavity, 
and the return of the memhrana tympani to its natural position. 

Secondly. The concave condition of the nierabrana tympani, 
which showed that there was very little air in the tympanic cavity, 
while there was no history of other disease to cause the concavity. 
The reason for assuming that the obstruction was at the faucial and 
not at the tympanic orifice, was the fact that the membrana tym- 
pani was translucent in one ear, and only slightly opaque in the 
other ; whereas, an amount of inflammation sufficient to cause ob- 
struction at the tympanic orifice of the tube, would necessarily be 
attended by considerable thickening of the mucous membrane 
lining tho inner surface of the memhruna tympani, and produce 
great opacity. 

Thirdly. The condition of the mucous membrane of the fauces, 
and tho result of the exploration of the tube by means of tho oto- 
scope. 

T. (treatment): The object is to reduce the mucous membrane 
covering the orifices of the tubes to a natural condition, so that the 
niuscles may be enabled to open them. For this purpose the solid 
nitrate of silver was applied to the mucous membrane of the fauces 
twice a week, and an astringent gurgle was also used ; small doses 
of quinine and colocynth were administered each night. The sur- 
face of the hotly was directed to be rubbed daily with a towel dipped 
in cold water, and abundant exercise on foot was recommended. 

The result of this treatment was to produce some slight improve- 
ment in the course of tho first week ; in the course of the second, a 
crack took place in the right ear, which was followed by a perfect 
restoration of the hearing in that organ ; the atr was then heard to 
enter, upon slightly forcing it ; but it did. not yet find its way during 
the act of deglutition. In the course of a day or two the left ear 
also improved greatly, though not equally with the right. This may 



38 THE DISEASES OF THE EAR. 

be accounted for by the thickened state of the mucous membrane of 
the tympanum on that side. 

Now the case just cited is illustrative of a large proportion of the 
cases met with in the practice of Aural Surgery. I mean, that in 
most cases, by a careful attention to the history, aided by an effi- 
cient examination of the organ, a medical man can form a tolerably 
accurate diagnosis. It has often been asked, how is it possible to 
.diagnose between anchylosis of the stapes and nervous deafness, two 
cases in which perhaps no disease of the organ is apparent ? But 
the history of the origin and progress of the cases, the nature of the 
patients* constitution, and the symptoms of the diseases, are quite 
sufficient to remove any difficulty on the subject. Indeed, so much 
is capable of being learned from the history of a case, that very 
often a pretty accurate diagnosis may be formed without ocular in- 
spection. For instance, in the above case my mind was made up as 
to its nature before making any examination. Again, the condition 
of the Eustachian tube is to be learnt by the state of the membrana 
tympani. When this tube is obstructed, the air that was contained 
in the tympanic cavity disappears, in part, in the course of a few 
hours, either from absorption or exosmosis. The effect of this par- 
tial disappearance of the air from the tympanic cavity is, that the 
membrana tympani becomes drawn inwards and very concave exter- 
nally ; and although this peculiar condition of the meml)rana tym- 
pani is met with in other diseases of the ear, their history differs 
from that of simple obstruction of the Eustachian tube. 

My object in citing the foregoing case has been to show that after 
carefully collecting the history of a case, and making a thorough 
inspection of the organ, there is generally not much difficulty in 
forming a tolerably correct diagnosis. 

Method of dissecting the ear, — In concluding these introductory 
observations, I will give some directions respecting the mode of re- 
moving and dissecting the petrous bone. 

The simplest method of removing the ears for the sake of dissec- 
tion, is, in the first place, to saw off the calvaria in the usual way, 
and then to take out both the petrous bones together, by means of 
two transverse vertical sections, one in front of the two petrous 
bones and the other posterior to them. The anterior of these sec- 
tions should pass in a liii/C a little anterior to the anterior clinoid 
processes, and the posterior in a line through the posterior third of 
each mastoid process. By means of these two sections, the trumpet- 



INTRODUCTION, 



shaped extremity of eacli Eustactiian tube, a portion of the mucous 
membrane of the fauces, and the whole of each petrous bone, toge- 
ther with the mastoid processes, can be taken out. The disadvan- 
tage of this procedure is the disfigurement which is apt to ensue 
from the falling in of the face. To avoid this disadvantage another 
mode of removing the ears may be resorted to ; this consists in 
taking out each petrous bone separately in the following manner: — 
The culvaria having been sawn off, an anterior Hection is to he made 
on each side on the same line as in the above plan, but extending 
only as far as the outer part of the body of the sphenoid hone ; a 
posterior section on each side is then to be made, as in the first plan, 
but not extending further inwards than the basilar process of the 
occipital bone. These two sections are to be made wilh a saw, or 
with a chisel and hammer ; the apex of each petrous bone is then to 
he separated from the sphenoid nml occipital bones, and each petrous 
bone (the outer ear and integument being detached and reflected 
downwards) is to be drawn outwards, taking care, by inserting the 
scalpel deeply, to remove as raucti of the soft parts as possible. 
With this second plan there is a difficulty in removing the whole of 
the guttural portion of the Eustachian tube ; with care, however, this 
portion may be removed, especially if the final sections separating 
the petrous hone from tho occipital and sphenoid he made to pass 
obliquely from above, downwards, and inwards. Tbo organ of hear- 
ing having been removed, the dissection may be conducted in the 
following manner : — The auditory nerve in its meatus should be first 
carefully examined, premising that a previous inspection has been 
made of tho portion of the brain to which the portio mollis and 
portio dura nerves are attached. The size of the external meatus 
having been ascertained by allowing a strong light to fall into it, its 
anterior wall is to be removed by the cutting forceps, made by 
McBBffi. Aah, of Broad Street, Golden Square ; the state of the epi- 
dermis, the ccruminoua glands, and secretion, the dermis, perios- 
teum, and bone, are to be noticed. The outer surface of the mem- 
brana tympani is then to be examined ; also the stale of its epider- 
moid and dermoid laminie, its degree of tension, and the amount of 
tuotion possessed by the malleus when pressed upon by a fine point. 
The next stop is to ascertain tho condition of the guttural portion 
of the Eustachian tube, to lay open the cartilaginous tube with the 
scissors, and then to expose the cavity of the osseous portion by 
means of the cutting forceps. In doing this, the tensor tympani 



40 THE DISEASES OF THE EAR. 

muscle i^ exposed ; its structure should be examined, and, if it has 
not a healthy appearance, portions of it should be submitted to mi- 
croscopic inspection. The upper wall of the tympanum is next to 

Fio. 1. 




Catting Forceps. 

be cut away, by means of the cutting forceps ; in doing this, great 
care must be taken not to disturb or disconnect the malleus and 
incus, which lie immediately beneath it. After the tympanic cavity 
has been exposed, the first step is to pull the tensor tympani muscle, 
and to ascertain how far it causes a movement of the membrana 
tympani and ossicles. The incus and stapes are now to be touched 
with a fine point, so as to ascertain their degree of mobility ; the 
tendon of the stapedius muscle is also to be pressed upon. The 
condition of the mucous membrane of the tympanum, and of the 
mastoid cells, is then to be ascertained, and any peculiarity of the 
cavity, the existence of bands of adhesion, &c., to be noted. The 
most delicate part of the dissection, viz., that of the internal ear, 
must now be undertaken. The cavities of the vestibule and cochlea 
are to be exposed, by removing a small portion of the upper wall 
of each. Before reaching the vestibule, the superior semicircular 
canal will be cut through and removed ; the membranous canal should 
be drawn out and inspected. As the cavities of the vestibule and 
cochlea are laid bare, it is desirable to see that the quantity of peri- 
lymph is natural, as well as its color and consistence. The outer 



INTRODUCTION. 41 

surface of the membranous labyrinth having been observed, it should 
be opened so as to expose the endolymph and otoconia, portions of 
all which parts should be removed for microscopic inspection. This 
having been effected, the remaining membranous semicircular canals 
are to be exposed, and the connection of the base of the stapes to 
the fenestra ovalis carefully examined. The last stage of the dis- 
section consists in removing parts of the lamina spiralis, in examin- 
ing them microscopically, and in exposing from within, by following 
the course of the scala tympani, the membrane of the fenestra 
rotunda. The only organ which now remains unexamined, is the 
stapedius muscle : in order to expose it, the course of the aquae- 
ductus Fallopii, beginning at the stylo-mastoid foramen, should be 
followed until the base of the pyramidal eminence, containing the 
muscle, is reached. 



CHAPTER II. 

THE EXTERNAL EAR. 

AXATOMICAL OBSBRYATIONS — USB OF THE EXTERNAL EAR — EFFECT OF THE REMOVAL 
OF THE EXTERNAL EAR (CASE) — PATHOLOGICAL OBSERVATION'S — MALFORMATIONS OP 
THE EXTERNAL EAR, WITH ABSENCE OF THE EXTERNAL MEATUS (CASES) — SUPER- 
NUMERARY EARS — INFLAMMATORY DISEASES — CHRONIC ERYSIPELAS CHRONIC EC- 
ZEMA — CYSTS — TUMORS — DEPOSITS — MALIGNANT DISEASE. 

Anatomical Observations. — The external ear is not unfre- 
quently described as a portion of the external auditory meatus. 
There are, however, peculiarities in the structure, functions, and dis- 
eases of these two divisions of the ear, that render it desirable for 
them to be considered separately. The external ear, comprising 
under that name all parts of the organ external to the meatus, is 
placed between the articulation of the lower jaw and the mastoid 
process, and consists of a basis of resilient cartilage, covered by 
common integuments, the two being connected by firm cellular tissue. 
On the outer surface of the ear, the integuments are so firmly at- 
tached to the cartilage that it is difficult to draw them apart, or 
even to move the one upon the other. The skin of the ear is so 
abundantly supplied with bloodvessels that a dried specimen I pos- 
sess, injected with size and vermilion, has, at first sight, the appear- 
ance of a mass of coloring matter, which, upon minute examination, 
is found to depend upon its vessels, that form a very dense network 

roughout every part. The lobule of the ear consists of a fold of 
integuments, which contains cellular tissue and a small quantity of 
adipose matter. The cartilage presents externally several depres- 
sions and elevations ; it forms the concha, the large concavity look- 
ing obliquely outwards and forwards, and bounded in front by the 
triangular projection called the tragus, which looks obliquely in- 
wards and backwards, facing the concha. Posterior, and slightly 
inferior to the tragus, is the antitragus. Extending upwards from 



EXTERNAL E A 



43 



[Be latter is the antihelix, which forms the rounded curved projec- 
tion of the outer ear, and divides above nnd in front into two 
branches ; of wliich the inferior and more prominent terminates 
under the helix, by which it is concealed; while the superior branch 
is very rounded, and seems as if it were the continuation of the anti- 
helix. Between the two branches is a fossa, calleti the fossa inno- 
minata, or the fossa of the antihcHx. The helix is the curved ridge 
which forma the posterior and snperior boundary to the ear : it 
commences in tlio cavity of the concha, wliich it divides into two 
parts, the inferior being the larger, and passes obliquely forwards 
and upwards above the tragus ; then curving backwards and down- 
wards, it is continuous inferiorly with the lobule. Above the tragus, 
the helix usually eonsista of a flat band of cartilage, the inner sur- 
face being applied against the superior branch of the antihelix, and 
the superior part of the concha. This arrangement of the helix 
screens a portion of the integuments beneath it from view and from 
contact with the air. This portion ought to be carefully cleansed 
and dried, especially in children. In some persons, the helix is 
absent ; and in certain cases of malformation there is no cartilage 
in the external ear. 

Use of the External Ear. — Opposite opinions have been 
entertained respecting the influence of the external ear upon the 
hearing power, Ilard denied that it was of any uee, while others 
have considered that it is of very material service in collecting the 
sonorous vibrations, and in conducting them to the meatus. Riche- 
rand says that the external ear may be removed without deafness 
being the consequence ; " For a few days after the loss, the hearing 
ia rather hard, but the infirmity gradually diminishes, the increased 
sensibility of the auditory nerve compensating for the imperfection 
of the organic apparatus." Dr. Hennen cites a case that he met 
with, in which the external ear was completely removed by a cannon- 
shot, and yet the sense of hearing was as acute as ever. Wepfer 
relates a case in which the outer ear was destroyed by ulceration, 
but the bearing po\fcr was not diminished. Itard says: "Every- 
thing combines to show that the auricle is absolutely useless in man ; 
that the hearing is not altered when it is removed, I have had 
occasion to assure myself most positively." (Traits dea Maladies 
de V Oreille, t, I, 1821.) lie owns, however, that this opinion has 
been opposed by various anatomists, among whom may be cited 
Valsalva and Haller, who state positively, that although the loss of 



44 



THE DISEASES OF THE EAR. 



the outer ear does not produce deafness, it is always accompanied 
by a diminution of the hearing power. Leschevin also states that 
those who have lost the external ear, or have it naturally too flat 
or ill-shaped, have the hearing less acute. {Cooper 9 Surgical Diet. 
7th Ed. p. 469.) 

An examination of the details of the cases from which deductions 
have been drawn respecting the functions of the external ear, shows 
that experiments suflSciently careful to decide the question were not 
performed. In those instances in which a diminished power of 
hearing was detected, the condition of the other parts of the organ 
IS not recorded ; and where the patients are described as hearing 
perfectly, no accurate test of the hearing power was employed ; nor 
does it appear that suflBcient care was taken to ascertain w^hether 
the supposed perfect hearing depended upon the organ that remained 
unmutilated. I am, therefore, happy that it is in my power to 
record a case in which these particulars were carefully noted. 

Case, The right external ear removed, — W. B., a sailor, aged 
33. The whole of the upper portion of the left auricle is absent. 
The antitragus remains, and also a portion of the tragus, about 
equal to it in size; below these the remnant of the lobe slopes 
gradually down to the side of the neck. He states that his ear was 
bitten off by another sailor at one of the Navigator Islands ; but 
the state of the parts ratlicr indicates a removal by a cutting instru- 
ment. The patient had come from California, where the practice 
existed of cutting off the right ear of a thief. He was anxious to 
return to California, but very unwilling to appear there without his 
right ear, and therefore applied to mo to aid him in obtaining an 
artificial substitute. His very long hair entirely concealed the 
remaining ear, and prevented any one from detecting the absence 
of the other. Long hair in men was, however, in California so sus- 
picious a feature, that wearing the hair short about the ears was not 
merely fashionable, but absolutely essential to a respectable appe^ir- 
ance. When examining the patient, I found that each meatus con- 
tained cerumen, after the removal of which by Ae syringe, he heard 
the watch equally well with cither ear, at a distance of two feet : 
nor, after careful experiments, could I detect any difference between 
the hearing power of the two ears. I sent this patient to the inge- 
nious Mr. Rein, from whom, I doubt not, he obtained what he 
required. 

Pathological Observations. — The two classes of disease of the 



TUK ESTEKNAL EAR. 



45 



external ear for which the assistance of the surgeou is sought, are, 
first, malformations, and, secondly, various kinds of infiammation ; 
to these may be added cases of cysts and tumors, whicU are, how- 
ever, comparatively rare. 

I, Malformations of the external ear generally coexist with par- 
tial or entire absence of the external meatus; but as the state of 
the outer ear usually attracts attention first, I ehall consider the 
two conditions together in this place. Somefimea the tragus is 
pressed backwards and inwards so as to close the meatus; in such 
a case, the patient must wear habitHally a small silver tube, or have 
a portion of the tragus excised. A much more serious malformation, 
and unfortunately one that is not uncommon, cousista in the absence 
of the cartilage of the external ear, together with the external mea- 
tus; the only representative of those parts being one or more soft 
and shapeless duplications of the integuments : sometimes, indeed, 
there is no vestige of cither meatus or auricle. 

The attention of the surgeon is called to cases of malformation of 
the external ear, in order that he may give an opinion, in the case 
of infants newly born, as to the amount of hearing they are likely 
to possess; or when children with this affection grow up with a 
certain degree of bearing, to decide whether an operation will 
probably be of any benefit : and, lastly, to do all in his power to 
diminish the deformity arising from the partial absence of the ex- 
ternal car. 

A case is cited by Mr. S. Cooper (loc. cit. p. 470) of a child he 
saw, when it was exhibited in London as a curiosity, which was 
wholly destitute of external ears, and in whom no meatus auditorii 
were visible. The child, nevertheless, "could hear a, groat deal, 
although the sense was certainly dull and imperfect." No careful 
investigation seems to have been made of Ibis case, nor is it stated 
whether the presence oF any meatus auditorii could be detected 
through the integuments. Judging from somewhat analogous cases 
which will be cited, it is most probable that the meatus was entirely 
absent. 

Fritelli and Overteuffer are also quoted by Cooper, as having 
seen cases in which the outer ear was entirely absent. The former 
says that the physiognomy of the child resembled that of an ape, 
and the latter states that bis patient heard very well. In some in- 
Btancea the auricle is deformed without any abnormal condition of 
the meatns or tympanum ; but, as a general rule, malformation of 



46 THE DISEASES OF TUE EAR. 

the external ear is accompanied by a defective development of the 
meatus and tympanic cavity. 

This subject has been examined with care by Professor Allen 
Thomson, who published a notice of several cases of malformation 
of the external ear, and of experiments on the state of hearing in 
such persons, in the Edinburgh Journal of Medical Science^ for 
April, 1847, to which is appended an account of the dissection of 
a similar case of malformation by myself. It appears that there 
are upon record only three dissections similar to those now under 
consideration : of these, one is described by Professor Jaeger of 
Erlangen, one is in the museum of the University of Edinburgh, 
and the third is one made by myself, at the request of the Patholo- 
gical Society of London, before whom it was brought by Dr. Lloyd. 
In the first two instances, one ear only was affected. " In both 
(quoting Dr. Thomson), the labyrinth appears to be quite naturally 
formed ; the cavity of the tympanum and the bony Eustachian tube 
exist, but Jire much smaller than usual. The chain of ossicles differs 
materially from the natural structure, being united, in one of the 
examples, into one straight and simple piece, and, consequently as- 
suming very much the form and appearance of the columella of birds 
or reptiles. The most striking departure from the normal form of 
the bone consists in the entire obliteration of the meatus externus, 
which seems to be connected with the absence of that portion of the 
temporal bone which forms the tympanic ring and lower side of the 
bony canal of the meatus, and the extension backwards of the arti- 
cular or true glenoid portion of the temporal bone to twice its natu- 
ral breadth. There is a total deficiency, therefore, of what may be 
termed the tympanic bone, or of that which forms the posterior non- 
articular part of the glenoid cavity of the temporal bone, intervening 
between the fissure of Glasser and the vaginal ridge of the spinous 
process. Were this part of the bone merely deficient, the cavity of 
the tympanum would be left freely open below ; but in the two bones 
now described, it seems to be closed by the unusual extension of the 
glenoid or articular portion of the bone backwards." In reviewing 
the cases recorded by him, and comparing them with the results of 
dissection. Dr. Thomson arrives at the conclusion that the following 
are the most prominent points of deviation from the natural form 
and structure: — 1st. An incomplete development of the integu- 
mental part of the apparatus, viz., the external auricle and outer 
part of the meatus. 2d. The absence of the membrana tympani 



THE EXTERNAL EAR. 



47 



ring aufl bony part of the meatus, in consequeuco of the incomplete 
development of the tympanic bone, or a port of the structure which, 
in the lower animals, bears that nniue. 3d. The defective state of 
the cavity of the tympanum and chain of small bones. 4th. Occa- 
sional irregularity or deficiency in the development of the malar, 
palatal, and maxillary portions of the face." My own dissection 
was laid before the Pathological Society in 1847 ; both cars were 
equally afi'ccted. The external ear consists of a fold of integument 
of much the same shape and size as the natural lobe, but directed 
forwards, so that the concave surface which usually looks outwards 
is directly applied to the surface of the head, and conceals tlie tra- 




d right Exlom 



gus, ivliich ia rather smaller than natural. There are two orifices 
on the upper part of the interior surface of the appendage, and 
one at its posterior part : these are the openings of mucous folli- 
cles. The meatus externus is entirely absent, and a slight depres- 
sion in the integuments is the only indication of its usual position. 
Upon removal of the integuments, no meatus or membrana tym- 
pani was discovered; but in their place is a flat surface of bone, 
which presents two fissures, one very narrow, with a direction for- 
wards, and a second, three or four lines in length, and from half to 
three-quarters of a line in breadth, commencing at the anterior and 
inferior part of tlie other fissure, with a direction downwards and 
slightly backwards. This fissure is covered by a membrane. The 
whole of the tympanic ring is absent, so that the mastoid and squa- 
mous portions of the temporal bone are only pai-ted by these fissures, 
the lower of which seems to represent the Glasserian fissure and the 
external meatus united into one. 

The membrane which covers the fissure appears to be the analogue 
of the membrana tympani. The zygomatic process of the temporal 



ASES OF TH 



bone ia represented by a smalt osseous layer developed in the middle 
of a ligament, which extends from the external part of the squa- 
mous portion to the orbit: the malar bone b absent, the external 




part of the orbital circle being formed by a ligament connecting the 
snperior maxillary and frontal bones. 

Upon removing the membrane just describ.ed, a cavity was ob- 
served lined with mucous membrane ; this is evidently the cavity of 
the tympanum, but so very much smaller than natural, as itself to 
resemble somewhat a fissure in the substance of the bone. It mea- 
Bures two dines in its vertical diameter, two and a half from before 
backwards, and about half a line from without inwards. This cavity 
contains two bones which are the analogues of the malleus and the 
stapes. The former consists of a narrow process directed upwards, 
and a globular body below, from which another process is directed 
inwards; but it has no connection with the stapes to which it ia 
superior. The stapes, instead of its two crura, has a process flat- 
tened above and below, and about three-fourths of a line in length; 
to the inner extremity is attached the base, firmly fixed in the 
fenestra oralis, while the outer extremity is slightly attenuated and 
presents no articulating surface. Over the stapes, and having a 
direction from above downwards and backwards, the portio dura 
nerve is seen unsurrounded by bone, but in contact with the mucous 



THE EXTERNAL EAR. 



membrane of the tympanum. The tcneor t^pani muscle is in a 
natural state, as is also the Eustachian tube, which opens into the 
anterior part of the tympanic cavity. The stapedius muscle is ab- 
sent ; the anditory nerve, cochlea, vestibule, and semicircular canals 
appear in all respects healthy. 



TbeTympBnioOfttity. 




d«Mi^hed fram euh olhcr, lire ta tbs right. 



The healthy state of the labyrinth would lead the surgeon to ex- 
pect that sufferers from this deformity might hear some sounds ; but 
considcriDg the absence of an external meatus and membrana tym- 
pani, and the imperfect state of the tympanic cavity, the compara- 
tively large amount of hearing enjoyed must be a source of surprise. 
In the following case there is every reason to suppose that the con- 
dition of the ears was similar to that just detailed ; yet the power of 
hearing was much more acute than in many instances in which the 
ear is perfectly developed, but in which there exists some thickening 
of that part of the apparatus essentia] to hearing. 

Case, CuTigenital malformation of both ears, atid absence of the 
meatus auditorit. — Miss A, J., aged 22, consulted me in 1851, on 
the recommendation of Dr. Theopbilus Thompson. On examina- 
tion, a very small fold of integmnent, in which was a delicate por- 
tion of cartilage, represented each external ear. The only vestige 
of the meatus auditorii was a very slight depression on each side, at 
the floor of which firm bone was felt. She heard the voice perfectly 
when spoken to loudly within a foot of the head, and best when the 
voice was directed towards the vertex of the head. She has a slight 
impediment in her speech, and her face is short and s(|uare-shM' 
the zygomatic process appears to be undeveloped. When 
tempts a forcible expiration with close nostrils, slie feels a ! 
of pressure in both ears. Does not hear so well durin 
Three months previously a surgeon had ma<le a crucial in 



50 



TUE DISEABES OF TH 



the depression in the left ear, liut no meatus auditortus was foima< 
The patient thoiijfht she heitrd slightly better while the surface was 
kept open, but it waa found impossible to prevent it from he&ling. 




RudimsDtu7 EitgniH] Enra. 

I advised that no further operation should be performed, and that 
she should rest content with the amount of hearing she possessed. 
She died about two years afterwards, but it was found impracticable 
to obtain a post-mortem examinntion. 

In some instances there has evidently been a coexistent abnormal 
development of the labyrinth, and the patients have been wholly 
deaf from birth ; it is gratifying, however, for the surgeon to be 
able to assure the friends of infants respecting whom he may be con- 
sulted, that, as a general rule, there is a sutfieient development of 
the organ for educational purposes and the ordinary intercourse of 
life. Thus one of the eases seen by Dr. Allen Thomson was a boy 
who went on messages for his father, a butcher. Ho could join in 
the eonvcrsation of those with whom be was intimate ; and even a 
stranger could communicate with him by employing slow, distinct, 
and rather loud articulation. A girl of only moderate intelligence, 
partly from weakness and partly from imperfect hearing, neverthe- 
less understood what was said to her, if spoken slowly and distinctly, 
and always answered by speech. Attempts to improve the hearing 
in similar cases by means of operations have invariably been unsuc- 
cessful ; first, becaose, as a rule, there is an entire absence of meataa 
and membrana tjmpani ; and secondly, because it has been found 
impossible to keep the aperture in the integuments from closing. In 
most cases of deformity of the external ear and meatus, a peculiar 
square shape of the face has been observed, the lower jaw being very 




THE EXTERNAL EAlt. 



short; and there is alao not mifrec|uently imperfect speech and de- 
glutition. Thus in tin infant, a month old, seen in consultation with 
Mr. Roberts, of St. John's Wood, 1853, the meatus auditorii being 
entirely absent, and the auricles only partially developed, tbo cbin 
receded much more thnn natural, and there was a not unfrequent 
regurgitation through the nose of the contents of the stomach during 
eructation. 

Supernumerary ears. — Cases have been recorded in which more 
than two ears have existed. Mr. Wilde says, that Cassebohm relates 
the case of a child with four ears ; two placed naturally, and two 
lower down in the neck ; in this instance, there were two petrous 
portions to each temporal bone, 

II. Inflammations of the external ear. 

The two kinds of inflammation to which the auricle is suhject are 
erysipelas and eczema. 

Chronic Ery»ipcla». — It is unnecessary here to speak of tJie acute 
form of erysipelas, since in its nature and treatment it does not 
differ from the same disease attacking other parts of the body. The 
chronic form of erysipelas, however, deserves attention on account 
of its frequency, the discomfort it produces, and its very tedious 
character. It sometimes originates in the acute form of the disease, 
and often remains during many years. By degrees the auricle be- 
comes hypertrophied and hardened, the meatus not unfrequently 
closed, and the car loses its natural form, its surface being exceed- 
ingly tender. This affection generally occurs in females beyond the 
middle period of life. 

Casf.~C. F., aged 49, admitted under my care at the St. 
George's and St. James's Dispensary, in 1849. She complains of 
much tenderness in both external cars, which, on examination, are 
observed to be red and very much thickened ; tlie integument and 
subjacent cellular tissue of the right ear are hardened, and the 
auricle scarcely presents tbo general form of the natural organ. 

The patient's health was much deranged. A solution of nitrate 
of silver, two grains to the ounce, vras applied to the ear, and mild 
preparations of steel were administered. Under this treatment the 
tenderness of the ear greatly diminished. 

Chronic Eczema, like chronic erysipelas, is most frequently found 
in females beyond forty years of age, in whom there is some consti- 
tutional debility ; it is, however, often met with in children. It is 
generally accompanied by extreme irritation of the auricle, which is 



52 THE DISEASES OF THE EAR. 

of a deep-red color, and often verj smooth and shining. Scales of 
epidermis are seen adhering to some of the parts, and from others a 
thin discharge exudes. In some cases, especially in adults, the 
dermis is hyper trophied, and the auricle loses it natural aspect. If 
neglected, it is liable to extend into the meatus, the dermoid layer 
of which also becomes red and sensitive, and sometimes tumefied, 
although not unfrequently no tumefaction is apparent ; the dermoid 
layer of the meatus throws out a discharge very similar to that 
formed on the external ear ; and sometimes the epidermis collects 
in quantities so large as to obstruct the canal, and give rise to those 
symptoms of pressure on the membrana tympani which will be more 
particularly alluded to under the diseases of the meatus. The treat- 
ment of chronic eczema is very similar to that of chronic erysipelas. 
Frequent ablutions with tepid water, combined with emollients, should 
be practised in the early stages of the affection, when the skin is very 
sensitive, and the latter should be protected from the air by oiled 
silk, or very thin vulcanized India-rubber. Afterwards, mild astrin* 
gents are to be used, and, as Mr. Wilde recommends, a solution of 
gutta-percha in chloroform may be painted over the surface several 
times until a complete coat has been formed ; which is to be renewed 
from day to day, as often as it peels off. The head should be kept 
cool ; and instead of the ears being studiously covered by layers of 
warm material, they should be exposed as freely as possible, and 
very soft pillows avoided. The meatus ought to be frequently 
syringed with tepid water, for the purpose not only of removing 
the dead cuticle and discharge, but also of soothing the irritable 
dermoid membrane. The introduction into the meatus of ear-picks 
and other foreign bodies, for the purpose of allaying the itching of 
tube, must be studiously avoided ; but if the itching becomes very 
distressing, a vapor-bath and hot injections should be resorted to. 
In later stages of the affection, when both dermis and epidermis 
become thicker than natural, the unguentum zinci or the unguen- 
tum hydrargyri nitratis may be employed. In addition to local 
applications, constitutional remedies should be employed. In adults 
any derangement of the general system should be attended to, alter- 
ative medicines administered, and great attention to diet enjoined, 
as well as abundant exercise in the open air. In children, these 
constitutional remedies require to be still more sedulously used, and 
where there is a tendency to glandular enlargement, sea or country 
air may be advantageously recommended. 



In adilition to the two kinds of inflammatory disorder just 
noticed, the auricle is soroetimea subject to a chronic inflammation, 
the scat of vrhich appears to be the cartilage or its immediate invest- 
ment: it is characterized by slight congestion and by extreme sensi- 
bility upon pressure. The auricle is also often the seat of chronic 
inflammation accompanied by excoriations ; but frequent ablution 
with tepid water and the use of mild astringents generally effect a 
cure. 

III. Cysta, Tumorsy Deposits, and Malignant Diseases. 

Chfiit. — The only kind of cyst to which the external car is sub- 
ject, is that formed by an effusion of blood between the cartilage 
and the integuments. It has most generally been found in insane 
persons ; and according to my friend Dr. Thumam, of the Wilts 
County Asylum, who has paid particular attention to the subject, 
and who has favored me with his experience upon it, it is not now 
80 prevalent as formerly. This he BHcribes to the fact that loss 
personal violence is now used. It has been thought by some to be 
peculiar to the insane ; such, however, is not the case, for a patient 
with this affection was admitted under my care, in the year 18.')2, at 
St. Mary's Hospital, and one. if not two, other cases of the kind 
have presented themselves to me, 

This disease, called by Dr. Stiff,' Iliematoma Auris, is divided by 
him into four stages. 

1. The stage of hypersemia, and probably chronic inflammation, 
as shown by the congestion and loss of the elasticity of the carti- 
lage. 

2. The stage of effusion ; an apoplectic layer is suddenly formed, 
causing obliteration of the ridges and depressions of the ear. 

3. The cystic stage; in a comparatively short time absorption 
commences, the ridges reappear, hut in altered shape. This stage 
may last for years. ^ 

4. Permanent induration, complete absorption of the fluid ; and 
occasionally atrophy of the ear. 

Dr. Thurnam calls this disease " Htematocele of the external ear." 
In a letter to me on the subject, he says: "In the first stage of this 
affection, I believe an effusion of blood exists between the folds of 
the integuments and around the fibro-cartilage of the ear : if punc- 
tured in this stage, there is a discharge of serum of the blood, mixed 



' Ucdica-Chirargicftl Rerii 



54 THE DISEASES OF THE EAR. 

with coagulnm. I think, however, the proper practice is, not to 
puncture in this early atagc, htit to apply evaporntiiig lolions. Even 
under this treatment, though stilt more if left to itself, the ttunor 




Hiemttoeela of the Eitt 



(Wilde). 



often increaaes so as entirely to disfigure the ear, and produces a 
large hot swelling of a livid red color. At the end of a week or 
two, according to circumstances, I have passed, with a. common or 
curved needle, a small seton through the long axis, pressing out the 
contents, which are now, in addition to their sanguineous nature, 
more or less purulent, and allowing the rest to escape gradually. At 
first the diminution of the tumor is trifling ; but under the use of 
the seton it gradually suhsidc^ and at the end of two or three weeks 
a certain amount of chronic thickening only remains. Where no 
such treatment has been adopted, the resulting deformity has been 
very marked, and has continued through life." 

The patient who came under my notice, at St. Mary's Hospital, 
was a man aged 26, a boxer, who had received a blow on the ear a 
fortnight previously. The cyst was about the size of a small wal- 
nut; it bad been punctured, and a transparent fluid was evacuated; 
it had, however, soon formed again. He did not return to undergo 
^ny treatment. 




THE EXTERNAL EAU. 



55 



Tumorg. — The lobule of the external ear is subject to hyper- 
trophy, and to the development of tumors in its substance. Tumors 
are also developed from the surface of the cartilage, or from the 
cellular tissue covering it, 




)r of Ihe Lobule (Wilde). 



Mr. Wilde relates a case of tumor in the substance of the lobule. 
"M. S., a female, aged 19, has a bard, firm, ovoid tumor occupying 
the centre of the lobe on each side, but largest on the left. It is 
of a stony hardness, and is quite distinct both from the cartilage 
above and the fleshy part of the lobe, which it appears to pass 
through. The skin covering it ia smooth, and of a fight pinkish 
hue, like that of a keloid tumor. It grew gradually from tlie orifice 
made for holding the ear-ring, and has been several months attaining 
its present size. The tumor upon the opposite side, which also 
surrounds the hole made for the ear-ring is much paler in color, 
and not larger than a garden pea. The girl states she expe- 
rienced a great deal of pain and soreness in the wounds made in 
piercing the ears, and that about three or four months afterwards, 
she was obliged to remove the ear-rings, on account of the irritation 
they produced. The large tumor was dissected out, and the ellip- 
tical aperture left in the lobo brought together with sutures. It 
healed kindly, and the disease did not return. A section of the 



56 THE DISEASES OF THE EAR. 

tumor exhibited a dense yellowish-white fibrous appearance, and was 
so hard that the nail made no impression upon it." 

Q-outy deposits are not unfrequent in the external ear. 

Scirrhvs. — Kramer, in his work on the Diseases of the Ear, 
devotes a section to the consideration of a disease which he entitles 
"scirrhous degeneration of the auricle." In its early stages, he 
describes its symptoms as analogous to those of erysipelas. As the 
disease advances, excoriation and ulceration of the auricle takes 
place, and the cartilage is perforated and destroyed. The auricle 
becomes nodulated and misshapen ; the nodules ulcerate. I have 
not met with the disease unless when complicated with disease of 
the petrous bone. Dr. Kramer cites three cases of supposed scir- 
rhous degeneration : of these the following occurred in the practice of 
Dr. Fischer : — A countryman, when eight years of age, perceived 
an itching, which depended on a scabby eruption of the head. This 
extended to the right ear, and its irritation being increased by 
roughly rubbing it with the hand, the skin was corroded. A redness 
and swelling of the ear, the certain attendants of inflammation, 
continued from that time, much encouraged by the plethora and 
strength of the individual. The disease now remained stationary 
for some years, but at the time of manhood it broke out afresh, and 
with increased intensity. During his twentieth year, it had ac- 
quired so enormous an extent that the whole auricle was converted 
into a knotty, deformed, and lumpy mass, in which the natural 
projection could scarcely be detected. At the anterior and inferior 
extremity of the antihelix the degenerate mass had begun to sup- 
purate. Dr. Fischer cut away with a knife the whole degenerated 
ear, and the wound healed in less than six weeks. 



THE EXTEBNAL MEATUS— ITS EXPLORATION. 



The external auditory meatus is a tube formed partly of cartilage 
and partly of bone. It extends in a transverse direction from the 
concha of the outer ear to the membrana tympani internally. Its 
length varies in the adult from an inch and a quarter to an inch and 
a half. 

The 0»»eov« Meatus. — There is a convexity about the midiUe of 
the lower wall of the osseous meatus which causes a slight central 
contraction of the calibre of the tube ; and this convexity, combined 
with a similar one in the anterior wall, often prevents the anterior 
and inferior foiirth or fifth of the membrana tympani being visible 



A Tartioal tcollDn oT tbs left Met 




Crom wilhoDt ioirards. 



to the surgeon during his exploration. The superior and posterior 
vails are slightly concave : the anterior wall and floor of the meatus 
extend three or four lines further inwards ; and as the membrana 



58 



TUK DISEASES OF THE EAR. 



tjmpaui is attached to the inner extremity of each wall, hence the 
oblique position of this membrane. The upper wall has intimate 
relations with the cerebral cavity ; the posterior is separated by a 
thin lamina of bone only from the mastoid cells; the anterior wall 
forms part of the glenoid cavity and the fossa parotidea. The outer 
orifice of the osseous meatus is of an oval shape, its longer axia 
being from above downwards, and slightly backwards. The ante- 
rior and inferior parts of the orifice are rough and scabrous, the 
fib ro- cartilage of the meatus being firmly inserted into them. The 
posterior and superior parts of the orifice are smooth, and perforated 
by numerous orifices for the transmission of vessels. The inner ori- 
fice of the meatus is round, and in the groove of its margin the cir- 
cumference of the membrana tympani is inserted. 

The diameter of the external meatus varies much. In some adults, 
it is so large as to admit the introduction into it of the end of the 
little finger for a considerable distance, and the membrana tympani 
may be seen by means of the ordinary daylight, without the lobe 
being drawn back. In other persons, the meatus ia so small as 
scarcely to admit a common goose-quill. The large size of the meatna 
depends generally upon the original conformation of the bony tube, 
but its contracted state is often the result of osseous development, or 
a thickened condition of the dermis, or the presence of bony tumors. 

The membranoua mea(u» consists of the following laminse, begin- 
ning internally : — lat, the epidermis ; 2d, the dermis ; 3d, the peri- 
osteum. Between the dermis and the periosteum of the outer portion 
of the tube are placed fihro-cnrtilagc, cellular tissue, and ceruminoua 
glands. The epidermis forms a cul-de-sac, which covers the whole 
of the outer surface of the dermis, and is prolonged over the outer 
surface of the membrana tympani, of which it forms the outermost 
lamina. In the outer part of the tube the epidermis is thick, and 
is perforated by the ducts of the ceruminous glands. Near to the 
outlet, it presents orifices for the passage of the hairs which fre- 
quently protect the entrance of the meatus. At the inner half of 
the tube, the epidermis ia extremely thin, with a shining surface. 
The scales which compose the epidermis are constantly thrown off 
from the free surface of the membrane : they mix with the cerumen, 
and in the healthy ear are excreted with it. 

The dermis also forms a cul-de-sac by being continuous with the 
dermoid layer of the membrana tympani. Near to the orifice of the 
meatus, the dermis difiers but little from that covering the cartilage 



THE EXTERNAL MEATUS — ITS EXPLO 



of the concha, with the exception that it gives insertion, particularlj 
in cUlerlj pereons, to nuiDerous short strong hairs. More internally, 
the dermis is remarkable for its extreme sensibility, and gives pas- 
sage to the duets of the ceruminons glands. The outer half of the 
dermis is finnly connected, anteriorly and inferiorly, to the fibro- 
cartilagc ; posteriorly and superiorly, where there is no fibro-carti- 
lage ; the dermis is connected to the superior and posterior parts of 
the osseous meatus by loose cellular tissue, in which the ceruminoua 
glands are placed. At the inner half of the tube, the dermis is 
intimately connected with the periosteum, the two membranes being 
frequently inseparable. 

The outer half of the membranous meatus contains, in addition to 
the laminic previously noticed, jibro-carttlage, which is continuous 
externally with that forming the estemal ear, and, internally, is 
attached to the rough margin of the osseous meatus by fibrous tissue, 
irhich admits of considerable motion taking place between the car- 
tilage and the bone. The outer part of the fibro-cartilage of the 
meatus projects and forms the tragus. The fibro-cartilagiuous meatus 



does not form a complete lube, being deficient at its posterior and supe- 
rior third, where the bloodvessels of the hone freely communicate with 
those of the meatus. The shape of the orifice of the meatus, consist- 
ing of fibro-cartilage, is more oval than that of the osseous meatus, 
and is composed, anteriorly and inferiorly, of the fibro-cartilage, 
covered by the dermis, posteriorly of the anterior border of the 



GO 



THE DISE4 



OF THE EAR. 



oooclia, wliich projects slightly forwards. The superior part of tlie ' 
orifieo does not contain any fibro-cartilage ; but in the remaining 
portions, the dermis is connected with the fibro-cartilage by Tery 
denae cellular tissue. That tbo orifice of the meatus extcrnus is 
oval ia shown by simply introducing tbo index finger within it in the 
living subject. It will be found that the finger (itself of an oval 
shape) enters some slight distance, and that its anterior and posterior 
surface are in contact with the corresponding surfaces of the orifiee ; 
hut if the posterior surface of the finger be directed upwards, and 
the anterior downwards, its entrance is impossible. The orifice of 
the external meatus is its narrowest part, and its cavity and the 
memhrana tympani are guarded by the slight projection posteriorly 
of the tragus, while the posterior margin of the orifice projects 
slightly forwards. Thus tlie introduction of a foreign body is pre- 
vented by the flap of the tragus covering the orifice ; and if that be 
pushed aside or penetrated, then the projecting posterior border of 
the orifice directs the body against the anterior wall of the meatus, . 
This condition of the orifice of the meatus is also of great use in 
preventing the sudden rush of cold air to the surface of the mcm- 
lirana tympani, and the passage of water to it, when the head is 
immersed, or copious ablutions are practised. The projection of the 
tragus backwards, and of the cartilage forming the posterior margin 
of the meatus forwards, consequently gives a curved form to the tube, 
wliich curvature is increased by the direction of the osseous tube 
being first slightly forwards, then backwards, and lastly, somewhat 
forwards again. 




At birth, only the rudiments of the 
present : these consist of a delicate 



external meatus are 
ring, which, however, ia < 



THE EXTERNAL MEATTB — ITS EXPLORATIOK. 



61 



inconiplete at the upper fom-tli, wliere the surface of the temporal 
bone 13 anjooth and slightly concave. The upper part of the mem- 
branoufl meatus rests on this portion of bone. The inner margin of 
the remainder is attached to the annulus auditoriua ; its outer sur- 
face is in contact with the adjacent tissues. As the child grows, 
the smooth superior surface is gradually developed into the concave 
upper wall of the meatus, and from the osseous ring spring the ante- 
rior, posterior, and inferior walla. 

In tlie exploration of the meatus, the object of the surgeon is 
threefold. 

I. To render the meatus as straight as is practicable. 

II. To dilate slightly the outer membranous and cartilaginous ' 
portion. 

III. To throw as much light as possible on the walls of the meatus. 

To straighten the meatus it is necessary to press the tragus for- 
wards, and the cartilage forming the posterior wall of the meatus 
backwards. Wien the meatus is very large, this may be accom- 
plished by simply pulling the outer ear backwards by the finger and 
thumb, at the same time that the tragus is pressed forwards by 
another finger ; but this is better effected by the aid of the gpeculum 
aurii, which at the same time dilates the orifice. Some writers have 
supposed that it is not desirable to use any instrument for tliis pur- 
pose; but the orifice of the meatus is generally so small that it is 
important to dilate it as widely as possible without causing pain, in 
order to allow the passage of a sufficient volume of the rays of light 
to permit the inspection of the surface of the meatus, and of that of 
the membrana tympani. That the orifice of the meatus is suscep- 
tible of being dilated is shown by placing the end of a finger in it, 
and then pressing it gently inwards, when the walls will be felt to 
yield slightly, and to embrace the finger firmly. 

For tlie proper inspection of the meatus a strong light is required, 
which can be so thrown as thoroughly to illuminate the visible sur- 
faces of the meatus externus and the membrana tympani. Sunlight 
ia the best ; but as its presence in our variable climate can rarely be 
made available, and as the surgeon must be prepared to make bis 
observations at all times of the day and night, and often on patients 
lying in bed, it is clear his usual resort must be to artificial light. 
By a careful use of this light, however, he may, with few csceptions, 
ftttain to such a knowledge of the condition of the surfaces illumi- 
nated as will suffice for his guidance. 



THE DISEASE 



OF THE EAR. 



There are two lamps which throw a good light into the meatus, 
M. Segalas'B and Mr. Miller's. 

Segalat't lamp is of very simple construction, but can only be 
used with gas. It consists of two vertical iron rods, the anterior 




mining Ihe Ear by ud of iiuilight.' 



of which is about four inches high, and surmounted by a gas-burner 
which communicates with the vulcanized indiarubber gas-tube. This 
vertical rod is connected by a horizontal rod, four inches long, with 
a second vertical rod about throe inches high, to the summit of which 
is fixed a circular reflector about four and a half inches in diameter ; 
and in the centre of which is an orifice for the surgeon to look through, 
about half an inch in diameter. Attached to tho horizontal rod is 
a ball and socket-joint, and a handle and movable piece by which 
the lamp may be held in the mouth, and thus both hands left at 
liberty. 

MiUer'a lamp, called after its manufacturer, was first suggested 
by Dr. Chowne ; but it has undergone great improvements in the 
hands of its maker. It consists of a wax candle, inclosed in a 
Palmer's spring tube, about six inches in length, standing upon a 
foot about two and a half inches in diameter and three-quarters of 

' In Ihia Bgara th< htad of the patient ODgbt to incline mors to th« right ihoaldst. 



THE ESTER NAL MEATUS ITS EXPLORATION. 63 

an ioch il(;ep, so as to hold the rciJector when not in use. For the 
top there is a cap which acte as an cxtinguiaher, and also aa a de- 
fence to the candle when carried ahout. This lamp will, I think, be 





found efficient and economical, not raferclj in cases of disease of the 
ear, but in all cases where a lamp is required, 

In addition to the lamp, specula are necessary for the examination 
of the ear. 

Speculum auria. — Various complicated and somewhat expensive 
inatruments have been invented for the purpose of straightening 
the outer hall' of the meatus, for slightly dilating it, and for con- 
centrating the rays of the sun, or of an artificial light, on the sur- 
face of the tube and on the membranit tympani. The oue in general 
use previous to the last ten years was the fon-epa-apeculuvt: it is 
made of steel, and consists of two haudles or branches crossing each 
other, but having a strong spring between them ; each of these 
branches is attached, at the extremity furthest from the handle, to 
half a metallic funnel, and when the handles are pressed together, 
the tiTO halves of the funnel separate. Is is used by placing the 
amall extremity of the funnel in the outer part of the meatus, and 



64 THE DISEASES OF THE EAR. 

then opening it so as to dilate the tube. The objections to the for- 
ceps-speculum, and indeed to all modifications of it, consist in its 
being cumbrous, expensive, and not efficient. Thus this instrument 
is too heavy to remain in the external meatus without being held ; 
on account of its weight and size it cannot bo used with delicacy, 
while a sensitive meatus is liable to be pained by it ; further, it re- 
quires the exclusive use of one hand, so that it cannot bo well em- 
ployed during the performance of an operation, or the use of applica- 
tions to the meatus or membrana tympani. Another great objection 
to the forceps-speculum is, that when the two portions of the funnel 
are separated in the meatus, two spaces are left between them, through 
which hairs or portions of epidermis and cerumen often project, and 
obstruct the passage of light. 

To remedy some of the above defects, the tubular ear-specuhim 
was invented by Dr. Gruber, of Vienna, and introduced to the notice 
of English surgeons by Mr. Wilde, in his paper on Otorrhea, pub- 
lished in 1844 in the Dublin Jaurnal of Medical Science, Mr. 
Wilde d^cribes it as consisting of " a small conical tube of silver, 
measuring about an inch and a half in length, five-eighths of an inch 
in width at the greater aperture, and varying from two to four lines 
in the clear at the small extremity." The interior and exterior of 
each extremity is polished, and both openings are circular. Two or 
three sizes are recommended. There can be no doubt that this 
speculum was a great improvement over any previously suggested ; 
but upon comparing its shape with that of the tube it is intended to 
explore, two grave defects are detected. The first is the coniform 
shape of its small extremity ; for the widest part of the speculum is 
introduced into the narrowest part of the tube, and its extremity 
projects into and obstructs that portion of the meatus which it is 
desirable should be free. With a speculum of this shape it is, 
secondly, very difficult to explore the whole of the meatus, and it is 
not sufficiently embraced by the meatus to retain its position without 
being held. These disadvantages of the conical speculum were ob- 
served by the late Mr. Avery, who devoted so much time, and did 
so much to facilitate the exploration of the various mucous canals. 
He suggested that the narrower portion of the speculum, for about 
three-quarters of an inch, should be of the same diameter throughout. 
There remained, however, the other very serious defect in the tubu- 
lar speculum of the circular form of its small extremity. As has 
been said, the surgeon can readily assure himself of the oval shape 



ATUB :TS EXPI,OR-*TIi 



65 



of the outer meatus, and that the anterior and posterior walls of the 
tube are flat and only slightly concave; a form that also partially 
obtains in the bone. It is clear, therefore, that when a circular tube 
is introduced into this oval-shaped meatus, it may press against the 
anterior and posterior walls, and yet leave a considerable space above 
and below it unoccupied. As a rule, therefore, it is impossible by 
means of this form of instrument to obtain a view of more than a 
small portion of the meatus and membrana tympani at the same 
time ; and should the meatus he very small, the circular tube does 
not give passage to a sufficient quantity of luminous rays to enable 
the surface of the membrana tympani to be discerned. Another 
disadvantage of the circular speculum is, that the pressure of its 
conve.i surface against the anterior and posterior walls of the meatus, 




', o! Bp«aU fur lb* purpose of iiaml 



which are nearly flat, is liable to produce pain, especially where the 
tube is small. It is therefore evident that the part of the speculum 
inserted into the meatus should be of an oval shape. This modifica- 
tion of the tubular ear-speculum was suggested by me in a paper in 
the Zancff, published in August, 1850; since which time most of 
these instruments have, I believe, been made of this shape, and have 
been found to answer every purpose for which a speculum auris can 
be required. In order to hold the speculum more firmly, it is desira- 
ble that the expanded portion should be somewhat flattened ; and this 
flattening should be at right angles with that of the smaller extremity. 
A set of three or four specula should be in possession of the surgeon. 
It haa been suggested that the tubular ear-speculum should be made 



66 THE DISEASES OF THE EAB. 

of glase silvered ; but the thickness of the material would occupy too 
large a portion of the cavity of tlie meatus. 

Mode of examination. — After the preliminary investigation has 
been conducted, the patient being as nearly as possible on a level 
with the Burgeon, the latter, taking the lamp in one band, should 
feel and inspect the external ear and the orifice of the meatus, with- 
out the use of the speculum. Having done this, a speculum adapted 
to the size of the meatus is to be taken in hand, and introduced into 
the orifice of the meatus, care being taken that the long diameter of 
each coincides. If the speculum enters very easily, and there ap- 
pears to be room for a larger one, the next size should bo selected, 
and the orifice fully dilated; for in all cases, the larger the speculum 
used the greater will be the quantity of luminous rays entering the 
tube, and the more complete the view of the meatus and membrana 
tympani. The speculum, having been introduced, is to be pressed 
slightly backwards, for the reasons I have mentioned, and then, by 




Ths Sargaan ciamiDiDg th« EiiterDBl Mettns bj meang af Mlller'a Lamp aad the 
TubniKr Speculum. 



means of the lamp in the other hand, the rays of light are to be di- 
rected successively on the several walls of the meatus and on the 
membrana tympani. The size of the difierent parts of the tube, the 



THE EXTERNAL MEATUS — ITS EXPLORATION. 67 

quantity, color, and position of the cerumen, if present, should be 
noted ; if absent, the state of the part of the tube in which it natu- 
rally exists, and the degree of vascularity of the dermis lining the 
inner half of the meatus. 

A considerable degree of care is required in the examination of 
the meatus in the infant and child. The total absence of the osseous 
meatus in the former, and its very limited size in the latter, should 
always be borne in mind, or the surgeon, when he introduces the 
speculum, is apt to press upon the membrana tympani. In many 
cases it is necessary only to open the orifice of the meatus, when the 
membrana tympani is at once seen without the introduction of the 
speculum any further. 



CHAPTER IV. 

THE EXTERNAL MEATUS (contitiued). 

ON FOREIGN BODIES AND ACCUMULATIONS OF CERUMEN IN 

THE MEATUS. 

FOREIGN BODIES IN THE MEATUS — MODE OF REMOVAL — CASES — CERUMIlfOUS GLAKDS — 
THEIR DISEASES — ACCUMULATIONS OF CERUMEN — THEIR CAUSES — ^TABLE OF TWO 

HUNDRED CASES IN WHICH THE CERUMEN WAS REMOVED — SYMPTOMS — EFFECTS 

TREATMENT — MODE OF REMOVAL — THE SYRINGE AND ITS USE — CASES. 

FOREIGN BODIES IN TUB MEATUS. 

Foreign bodies are frequently introduced into the outer meatus. 
Among those which have fallen under my own notice may be named 
beads, slate-pencil, leaves, a shell, a pea, sealing-wax, a percussion- 
cap, a pin, a piece of paper, seeds of grass, tobacco, wool, cotton- 
wool, human hairs, bacon, lint, camers-hair pencil, and cameFs hair. 
When a body is put into the meatus by design, it is either done by 
a child in play, or by an adult for the purpose of medical treatment, 
or an alleviation of the itching of the tube. When a patient is sus- 
pected of having a foreign body in the ear, the first step of the sur- 
geon is to make a careful inspection of the tube in sunlight or with 
the speculum and the lamp, with the view of ascertaining whether 
there really is anything present. In a great number of cases, having 
explored the whole of the meatus, and seen the membrana tympani, 
he will be able to assure the patient or the friends that no foreign 
substance is there. For want of this pre-inspection, lives have been 
destroyed in attempting to extract from the ear imaginary bodies 
which had never lodged there. Medical men are not generally aware 
of the impunity with which a foreign substance may continue for a 
time in the meatus. It is not uncommon to find a mass of hard 
cerumen in contact with the whole of the meatus and with the outer 



THE EXTERNAL MEATUS. 



69 



surface of the membrana tympani, without causing any pain or inflam- 
mation; and I have frequently removed other aubstances, as bcada, 
peLblea, kc, which had been either in contact witli the meoibrana 
tympani or in itH immediate vicinity, without causing any painful 
irritation. Nor ia this remarkable when it is remembered that the 
meatus and outer surface of the membrana tympani are a continua- 
tion of the outer skin, and, like it, covered with a layer of epidermis. 
The meatus and membrana tympani are extremely sensitive when 
pressed upon by hard or rough substances ; but soft, smooth bodies 
may be gently pressed against them without exciting pain. Thus 
the artificial membrana tympani, made of ^nilcanized india-rubber, 
is placed against the outer surface of a perforated membrana tympani 
without producing any unpleasant sensation. 

When a foreign body bas been detected in the external meatus, it 
should be removed ua soon as possible. The syringe and warm water 
are, as a general rule, quite sufficient to remove all rounded solid 
bodies. I have succeeded in extracting beads and other hard sub- 
stances which appeared to he impacted in the meatus, by means of 
the syringe only, though a good deal of time is occasionally required- 
It may at times be useful to move the body slightly by means of a 
probe a little bent downwards, so as to facilitate the passage of the 
water to the back of it ; for the mode by which the syringe acts, ia 
in forcing the warm water inwards behind the foreign body, and thus 
gradually expelling the latter outwards. Mr. Wilde and other 
writers recommend the use of the curette, spatula, or forceps, in the 
extraction of extraneous subt^tances from the meatus : but I have 
rarely been obliged to use any of these instruments, and resort to 
them should be avoided if possible. Dieffenbacb, who advocated the 
use of a curved director, or curette, must have met with cases show- 
ing the practice to be dangerous; for lie says, "Should violent 
bleeding supervene, and there be no likelihood of completing the 
operation at one sitting, cold and afterwards warm applications are 
to be resorted to, to prevent suppuration," It is also almost impos- 
sible to pass a curette between the extraneous substance and the 
meatus without impelling that substance inwards, in which case it is 
very apt to be pressed forciOli/ against the membrana tympani, and 
cause inflammation. Cases are sometimes met with in which the 
most lamentable results have followed attempts at removing foreign 
bodies by instruments. Death itself bas not unfrequently happened; 



70 THE DISEASES OF THE EAR. 

and where the life of the patient has been spared, the ear has some- 
times been destroyed and the portio dura nerve paralyzed. 

Should a patient apply for relief who has much inflammation and 
tumefaction of the meatus, consequent perhaps upon attempts pre- 
viously made to remove the body by instruments, the best course is 
to apply leeches and fomentations to subdue the inflammatory 
symptoms, before attempting the extraction by the syringe. 

In certain cases the presence of a foreign body in the meatus 
gives rise to coughing, and even to vomiting ; symptoms which seem 
traceable to irritation of the auricular branch of the pneumo-gastric 
nerve. A patient under my care, with a portion of dead bone in 
the meatus, suffered under a cough, which no treatment subdued, 
but which disappeared as soon as the bone was removed. In a 
notice of Professor Romberg's work, in the British and Foreign 
Medical Review^ Vol. XVII, it is stated that Arnold met with a 
case of chronic vomiting in a child, which long resisted all medical 
means, but which was cured by removing a bean from each of the 
child's ears. 

There are substances of a different character from those already 
alluded to which are not so easily removable by the syringe. These 
are wool, cotton-wool, tobacco, leaves, paper, and similar soft mate- 
rials, which expand in the tube and perfectly fill it. If the syringe 
fails to remove these bodies, they can be seized with the lever-ring 
forceps, with which they can be easily withdrawn.* Insects some- 
times enter the meatus, and are apt to cause more irritation than 
the presence of solid bodies. If they touch the membrana tympani, 
they cause extreme sensitiveness of it, and spasmodic contraction of 
the tensor tympani muscle. The use of the syringe, or, if that be 
not at hand, the pouring of a little warm water into the ear, affords 
instant relief. Foreign bodies which press upon the outer surface 
of the membrana tympani arc apt to force the chain of bones inwards, 
and thus press the stapes towards the vestibule, causing the peculiarly 
distressing symptoms of giddiness and confusion in the head which 
not unfrequently attend upon an accumulation of cerumen. These 
cease as soon as the foreign body is extracted. 

There is little known as to the effect of narcotics introduced into 
the external auditory meatus : but I have every reason to believe 
that the narcotic property of a piece of tobacco in the meatus was 
the cause, in one instance, of very serious cerebral derangement. 

^ See a description of this instrument in Chapter YI. 



THE ESTEnSAL 



7i 



It is probable tbat, In the following citse, the foreign body escaped 
spontaneously. 

M. S., aged 9, was brought to mc by a raeilical man, in January, 
1852. He stated that, on the previous evening, the mother of the 
child had seen her put a bead into the right ear ; that he himself 
had scon what he supposed to be the bead, but he had been unable 
to extract it by the forceps. By means of the lamp the surfaces of 
the meatus and membrana tympani were seen, and the ilermis 
throughout was much congested, especially near the orifice where 
the forceps had been applied, but no foreign substance Could be de- 
tected, 



CASES OP FOREIGN IIODIEB REMOVE!) FROM TUE EXTERNAL MEATUS. 



Case I. Slate-pencil in the ear of a child. — J. S., aged 7, was 
brought to me at the St. George's and St. James's Dispensary, on 
November 28th, 1849, her mother stating that she had pushed a 
piece of slate-pencil into the right car. She had not complained of 
pain, and had slept well. Upon examination, by means of the 
speculum and lamp, a rough piece of si ale-pencil was observed lying 
on the floor of the meatus, one end being apparently in contact with 
the membrana tympaui, while the other looked towards the orifice 
of the meatus. It was easily removed by the syringe and warm 
water, and found to be nearly half an inch long, and a quarter of 
an inch broad. The membrana tympani was red, the bloodvessels^ 
of its dermoid layer being distended. The patient did not complain 
of pain, and in a few days the membrana tympani was healthy. 

Case II. A pcrcusnion-cap in the ear for fifteen year». — C. E.. 
aged 26, was admitted at St. Mary's Hospital in November, 1852. 
She said that lately she had felt somewhat deaf in both ears. 
Upon examination, a mass, like hardened wax. was observed near 
the orifice of the left meatus. It was removed by the syringe, and 
proved to bo a percussion-cap surrounded by wax. The patient 
said that she remembered, when about 11 years of age, she put a 
cap into her ear, but she believed it had been taken out, and ha<l 
never thought of it since. The membrana tympani was concave, the 
Eustachian tube natural, and the power of hearing was nearly gone. 
Right ear: hearing distance seven inches, membrana tympani dull, 
concave ; Eustachian tube natural. It appears that the thickening 



72 



THE DISEASES OF TUE EAR. 



of tlie right membrana tympani had recently caused a dulnesa of 
hearing in that ear: the left ear had doubtlesa been useless for some 
time ; hut so long as the right car remained perfect, the defect in 
the left iTas not observed. 

Haim are apt to collect in the meatus ; they either enter in small 
pieces while the hair ia being cut, or those growing at the orifice &11 
inwards : great iritation is caused by them. 

Ca»e III. A collection of hairs in the external meatus, — W. S., 
aged 69, complained of an extremely unpleasant crackling in the 
right ear whenever he moved the htad or ear. It came on two 
months before seeing mc, after bathing in the sea; and be had h&d 
a similar attack some years pre%-ioualy, which had subsided sponta- 
neously. The hearing distance was three inches. A large mass of 
short hairs was syringed out of the ear ; the symptom of crackling 
at once til sapp cared, and the hearing distance became two feet. 
Another gentleman, from the same cause, was troubled with excessive 
itching. 




Case TV. A pin impacted in the meatus. — A. R., a servant, aged 
35, came in great fear and in some pain, complaining that while 
picking the left ear with a pin »he had dropped it into the ear, and 
was unable to remove it. The Iieiul of the pin was seen to lie cloae 
on the membrana tympani at its lower part, and the point seemed to 
be inserted in the membranous meatus. The syringe proved ineffec- 
tual, and I therefore had to remove it with the rectangular forceps, 
an instrument of great utihty where the extraneous substance cannot 
be otherwise removed. On attempting to withdraw the pin, I dis- 
covered that its point was firmly fixed in the dermis, and that the 
only way to extricate it was to seize it by the middle, push it gently 



THE EXTERNAL MEATUS. 78 

inwarils against the metobrana tympani, and then suddenly draw it 
out. 

Cotton-wool, — In one case a portion of cotton-wool had beun in 
the right ear for ten years without producing any other symptom 
than a feeling of fulness. In the following case, where it rested on 
the meinhrana tympani, symptoms similar to those of pressarc on 
the brain were very decided. 

Case V. Vottott-wool in the meatus. — The Rev. 0. M., aged 55, 
consulted me in 1849. Since an attack of measles when a child, 
has had a discharge from the left ear ; and has been accustomed to 
push a portion of cotton-wool into the meatus. Has lately suffered 
from giddiness and a sensation of weight on the head ; which symp- 
toms hia medical advisers thought were produced by derangement of 




the stomach, as during attacks of dyspepsia he was decidedly worse. 
Upon examination a large quantity of eotton-wool was observed in 
the meatus in contact with the menilirana tympani : it had evidently 
been pushed in by other portions which had been thrust upon it. 
The cotton was removed by means of the syringe, and was found to 
Lave closed an orifice in the membrana tympani. After the removal 
of the cotton, the attacks of giddiness wholly subsided. 

In a dissection, of which a drawing is subjoined, I found a piece 
of cotton-wool in the meatus, where it had probably remained for 
many years; and it had so largely dilated the bony meatus, that the 
index finger could be passed in as far as the membrana tympani. 

Cage VI. A shell in the meatus j removal by itistrmntnts ; para- 



74 THE DISEASES OF THE EAR. 

lysu of the portio dura nerve. — Miss A., aged 14, consulted me, in 
May, 1853, on account of complete deafness of the right ear and 
paralysis of the right side of the face. Her father stated that eight 
years previously she had, in play, put a small shell into the ear ; 
that the surgeon, in endeavoring to remove it, forced it deeper into 
the ear, breaking the shell, and causing intense pain. After its re- 
moval there was much discharge from the ear, and in a few days the 
muscles of the right side of the face lost their power, which they 
have not regained. Upon examination there was no vestige of the 
membrana tympani ; the mucous membrane of the tympanum was 
very thick and red, and there was not the slightest power of hearing. 
Case VII. Tobacco in the meatus; pain and numbness in the 
head; partial stupefaction^ inability to tvalk straight. — M. B. S., 
aged 60, applied for relief in 1843. He stated that for four months 
he has had pain and a sensation of numbness in the right side of the 
head, which feelings are much aggravated at times. He also com- 
plains of giddiness, and sometimes reels across a room ; at others he 
is obliged to sit down, feeling quite oppressed and stupefied. He 
has also suffered from indigestion. Upon consulting a medical man, 
he was treated by cupping, purgatives, &c., but without relief. Upon 
examination of the right external meatus, a considerable quantity 
of black matter was seen, which was easily removed, and was found 
to consist of tobacco in a moist state, mixed with cerumen and wool. 
The next day the head-symptoms were much diminished ; in a few 
days they wholly disappeared, and the patient remained free from 
them. The tobacco had been introduced into the meatus a short 
time before the attack, on account of toothache. The mass was soft, 
and so loosely packed that it appears probable the symptoms were 
caused by the narcotic principles of the tobacco, rather than by its 
pressure on the membrana tympani. In cases of pressure, too, the 
symptoms disappear at once on the removal of the cause ; whereas, 
in the present instance, they subsided slowly. 



THE CBRUMINOUS GLANDS AND THEIR DISEASES. 

The ceruminous glands surround the outer half of the membra- 
nous meatus, with the exception of the portion situated within a line 
or two of the orifice. They are contained in the cellular tissue be- 
neath the dermis, on the surface of which the ducts open. Kolliker 



THE EXTERNAL MEATUS. 



75 



bfeS recently shown them to be modifications of the sudoriferous und 
not of the sebaceoua glands, as was previously supposed. Tlie ceru- 
men secreted by these {(lands forms, in the perfectly healthy ear, a 
band about half an inch in length, and half a line thick. This band 
should be of a consistence just sufficient to onablo it to retain its 
position, at the same time that it can collect the small particles of 
dust, &c., which float in the atmosphere, and prevent their accumu- 
lation on the surface, or in the vicinity of the membrana tynipani. 
Two other functions ascribed to the cerumen are, that by its bitter 
taste it prevents the ingress of insects ; and that in some peculiar 
manner it assists the power of hearing. Its principal use is unques- 
tionably to arrest and collect the particles of dust. Its bitterness 
may possibly deter the entrance of insects ; but the idea that it me- 
chanically assists in collecting or conducting the sonorous vibrations 
to the labyrinth, or that it is of any use, in fact, in the actual pro- 
cess of hearing, is, in my opinion, quite erroneous. No doubt its 
absence is very frequently accompanied by a diminution of the hear- 
ing power ; but this absence appears rather to result from the sym- 
pathy which exists between these glands and the deeper structures 
of the ear. Very often, when these return to their normal state, 
the ceruminouB glands again pour out a healthy secretion. The most 
convincing proof that the cerumen does not mechanically assist in 
the function of hearing is, that in many cases, when the ceruminons 
glands alone are affected, and their secretion consequently arrested, 
no diminution in the hearing power can be detected even by the use 
of the moat delicate tests; and cases must frequently occur to medi- 
cal men, where there has been a long-continued discharge from the 
surface of ihe dermis, no cerumen being secreted, without perceptible 
diminution of the hearing power. It is also well known that the 
entire removal of the ceruminons secretion does not impair the hear- 
ing power ; and in no case of deafness has it been shown that the 
introduction of cerumen or of any substance to supply its place, or 
even the promotion of its healthy secretion under the influence of 
stimulants, has in the least degree improved the bearing. Indeed, 
if the peculiar properties of soft cerumen be considered, it must be 
manifest that its function would be rather to absorb superabundant 
sonorous unduktions than to increase their intensity. The natural 
method whereby the cerumen when it has performed its duties is 
expelled from the ear, is the action upon the external meatus of the 
condyloid process of the lower jaw, during the movement of masti- 



76 THE DISEASES OF THE EAR. 

cation and articulation. By these movements, the cerumen is brought 
quite to the orifice of the meatus, whence it either falls out in small 
particles, or is removed by the towel. 

Dtaeaaea of the Ceruminous Glands. — The ceruminous glands 
sometimes pour out a too abundant secretion, which is either of a 
light brown color and softer than natural, or hard and dark colored ; 
it may also be entirely absent. When soft and semi-liquid, it is 
generally found in young patients having a tendency to glandular 
enlargements, and in whom the dermis of the meatus is hypertro- 
phied ; thus, without any accumulation beyond that which' adheres 
to the walls of the meatus, the cavity is nearly filled with cerumen. 
It is, however, generally found in a state harder than natural ; and 
this condition, by preventing its free escape from the ear, gives rise 
to that very common affection, accumulation of cerumen in the ex- 
ternal meatus. 

Collections of Cerumen. — Cerumen accumulates in the external 
meatus from two different causes : one^ a primary affection of the 
ceruminous glands ; the other, a secondary and sympathetic derange- 
ment of the deeper-seated cavities. Thus, while in a large number of 
cases the removal of the accumulated cerumen is productive of im- 
mediate relief to the deafness ; in others, the hearing is only par- 
tially or not at all benefited by the operation. In order to ascertain 
the numerical relation between the cases of accumulation that are 
cured, and those that are only relieved, by the use of the syringe, I 
have arranged in a tabular form the results of one hundred consecu- 
tive cases that have occurred in my private practice. 



V Ttlli. 


EXTEKNAL ME 


77 ^1 


* TABLE SHOWISO TBE EFFECT ON THE POWER OF HEARING Or THE RE- ^M 


MOVAL OF AN ACCUMDLATION OF CERUMEN IN ONF. HCNDRED OABEB; ^| 


THE NORMAL DISTANCE OF TESTINO-WATCK BEING THREE FEET. ^H 


i 


"""'""«" 


V4I,. 


■■-■=■■■- ■ 


Eight Ear. 


UftB.T. 


Bighl Ear. 


L^ Ear. 


22 


I inch 


6 inches 


18 inches 


18 inches 


22 




half an inch 


normal 


normal 


32 


7 ioclies 


crack of nails 


12 inches 




70 


contact 


contact 


contact 


contact 


33 


bull' no inch 


half mi inch 


normal 




35 


2rect 


half an inch 




normal 


45 




half an ii>ch 


2 inches 


2 inches 


15 


half an inch 


3 inches 


norcnal 


normal 


44 




half an inch 


normal 




, 59 


1 inch : no ceramen 


cmck of nails 


] inch 


crack of nails 


26 


crack of nails 




1 inch 


3 inches 


18 


4 inches 


half' an inch 


normal 


normal 


29 


5 inchea 


normal: no cerumen 


normal 


normal 


8 




contact 


3 inches 


contact 


74 


half an inch 


half an inch 


half an inch 


half Bi. inch 


49 


G inches 


G inches 


6 inches 


G inches 


63 


crack of nniU 




4 inches 


2 inchea 


28 


half an inch 


norma!: no cerumen 


normal 


normal 


26 


linch 


half an inch 


8 inches 


7 inches 


26 


half an inch 


2 inches 


normal 


12 inches 


49 


9 inches 


t inch 


'J inches 


1 inch 


19 


7 inches 


linch 


7 inches 


24 inches 


32 


quarter of an inch 


half an inch 


normal 




S3 




half an inch 


normal 


normal 


30 


half an inch 


10 inches 


fi inches 


normal 




2 inchM 


\\ inch 


2 inches 


half an inch 


41 


18 ioi-hes 


S inches 


18 inches 


8 inches 


65 




contact 


2 inches 


2 inches 


27 


preKBoro 


pressure 


half an inch 


3 inches 


44 


4 inches 


pressure 


C inchea 


3 inchea 


25 


24 inches 


I inch 


normal 


3 inches 


40 


pressure 


normal 


normal 




65 


crack of nails 


crack of nulls 


■i inchea 




27 


13 inches 




normal 


normal 


27 




pressure 


18 inches 


18 inches 


70 


pre&sun) 


pressure 




1 inch 


66 




pressnrc 


normal 


7 inches 




2 inches 


•i feet 


normal 


normal 


20 


2 inches 




2 inches 


2 inches 


S3 


24 in.: no cerumen 




24 inches 


12 inches 


38 


contact 


half an inch 






7 


2 inches 




^4 inchea 


normal 


14 


2 inches 


u inches 


24 inches 


24 inches 


29 


2 inches 


6 inches 


normal 


12 inches 


40 


4 inches 


pressure 


8 inches 


5 inches 


14 






6 inchea 


normal 


35 


7 inches 


half an inch 


normal 


normal 


k 


2 inches 


coDtact 


24 inches 


normal 



THE DISEASES OF THE BAB. 



5 


HKAWM^D^T^CX BX.ORE 


""■" ™;;«" "'" 




Rigkl Bar. 


Ufl Ear. 


Right Ear. 


Uft Ear. 


45 


16 inches 


3 inches 


24 inches 


e inches 


19 


normal : no cerumen 


contact 


normal 


normal 


28 


normal: no pa rumen 


preasoro 


normal 


normal 




normal '. no cerumen 


half an inch 


normal 


normal 


46 


quarter of lin inch 


pressure 


half an inch 


half an inch 


23 


4 inches 


5 inches 


normal 


normal 


44 


pressure 




normal 


normal 


25 




I'Tner^ 


normal 


normal 


14 


2 inches 


2 inches ' 






60 


1 inch 


linch 


9 Inches 


9 inches 


27 


normnl 


half an inch 




half an inch 


50 


18 inches 


pressure 


IS inches 


24 inches 


20 


2 inches 


i inches 


normvl 


norma! 


11 


2 inches 


half an inch 


8 inches 


e inches 


60 


2 inches 


normal 


normal 


normal 


45 


half an inch 


half an inch 


1 inch 


1 inch 


5 


crack of nails: 


2 inches 


crack of nails 


4 inches 


33 


10 inches 


2 inches 


normal 


normal 


2H 


linch 


24 inches 


24 inches 


24 inches 


41 




contact 


normal 


24 inches 


14 




2 inches 


12 inches 


24 inches 


24 


preasnre 


pressure 


normal 


2 inches 


GO 


I inch 








34 


normal; no cerumen 


24 inches 




normal 


19 


2 inches 


linch 


24 inches 


24 inches 


61 


2 inches 


2 inches 


3 inches 


3 inches 


65 


crack of nails 


crack of nails 


crack of nails 


crack of nails 


24 


contact 


2 inches 


normal 


normal 


40 








8 inches 


CO 




crack of nails 




crack of nails 


56 


quite deaf: no ecru. 


contact 


quite (leaf 


6 inches 


21 


normal : no cerumen 


6 inches 


normal 


normal 


40 




4 inches 


6 inches 


12 inches 


51 




contact 




3 inches 


60 


6 inches 


fi inches 






55 


crack of nails 


contact: no cerumen 


contact 


contact 


41 


12 in.: no cerumen 




12 inches 


6 inches 


27 


normal: no cerumen 


half an inch 


normal 


4 inches 


60 


normal: no cenimeu 


contact 




1 inch 


46 


2 inches 


half an inch 


24 inches 


6 inches 


35 


normal: no cerumen 


pressure 


normal 


12 inches 


45 


3 inches 


3 inches 


3 inches 


3 inches 


74 


crack of nails 


2 inches 




6 inches 


49 


half an inch 


half an inch 


4 inches 


4 inches 


uT 


half au inch 


2 inches 


1 inch 


3 inches 




crock of nails 


crack of nails 


t inch 


linch 


39 


pressure 


crack of nails 


normnl 


normnl 


as 


4 inches 


contact 


normal 


14 inches 


2.> 


2 inches 


normal : no cerumen 




normnl 


52 


8 inches 


1 inch 


8 inches 


2 inches 


54 


normal : no ceromcn 




normal 


C inches 


11 


OOnUCl 


contact 


12 inches 


12 inches 



THE EXTERNAL MEATUS, 



An analjBis of the foregoing 100 cases shows the following to bo 
the result of the examination of the 200 ears : — 



;■» in whi 
{■ni in whi 
{■rs in whi 


uh the h«ui 
oh the honri 
oh the htiu-l 
■tramrn, 
oh there wi 
, ths n(ipo(i1 
oh Ihore wii. 
, lh« oijpnsil 


ng power not grontlj improreii 

ng powfr w» only .lightly improTed, . . , 
Log power wm the mme ajirr ms br/are the removal 


SuBlnwIi) 


te ear be! 


1. and iQ which the 


bearing power WB« 


Cars in whi 


; tutinwhiohthehe 
ng affected, . 


laring power wa* not 



It thus appears that of the 165 ears from which ceriunen was re- 
moved, onlj 60 were cured; that, including the 43 cases which were 
much improved, there were 103 cases of great amelioration, while 
there were 62 ears that were either but slightly or not at all im- 
proved. Thus, out of the 165 ears from which a collection of ceru- 
men was removed, there were 105 in which there was some other 
disease, the restoration of the hearing not being perfect. The pre- 
sence of cerumen in the external meatus may bo symptomatic of 
several affections, as obstruction of the Eustachian tubes, or thick- 
ened condition of the tympanic mucous membrane, debility of the 
auditory nerve, anchylosis of the stapes, &c. ; it is therefore impor- 
tant that every case should be carefully examined after a collection 
of this kind has been removed ; because, if the hearing power be 
not wholly restored, some other disease is present which requires at- 
tention. 

The causes producing accumulation of cerumen in cases not com- 
plicated with other diseases, are, — a narrow calibre of the meatus ; 
the application of cold ; the admixture of Just with the cerumen; 
and, not un frequently, the practice of pushing into the ear the point 
of a towel, whereby the cerumen is pressed into a mass towards the 
membraua tympani. 

The tymptomt of an accumulation of cerumen are : sudden deaf- 
ness, often following a cold by whieli the dermis is tumefied ; bath- 
ing or the introduction of water into the ear. This deafness is 
often better in the morning ; is increased by the movements of the 
jaw during maBtication ; and often disappears aa suddenly as it 
oame, with a cracking sound in the car. The cause of the sudden 
appearance and disappearance of the deafness is the movement of 



80 



THE DISEASES OP THE EAR. 



the mass of cerumeu; when it ia no placed as to allow f 
bratioiiH to pass between it and the wall of the meatus, the hearing 
returns ; but when it again comes in contact with tbe meatus, the 
deafness recurs. Oftentimes a feeling of fulness in the ear is com- 
plained of; not unfrequently there ia singing and giddiness, and 
sometimes considerable pain. 

The symptoms of a collection of cerumen in the meatus vary 
according to the nature and position of the mass. Sometimes the 
whole of the meatua ia distended by cerumen, the inner end of which 
lies in contact with the outer surface of the membrana tympani, of 
which it often forms a cast. In these cases, there is often giddiness 
arising from the pressure on tbe chain of ossicles. The symptoms 
■ of pressure on the brain are familiar to most surgeons ; but it ia not 




nui Tjmtuim. 



generally known that presaui-e on the contents of the labyrinth pro- ' 

duces somewhat analogous symptoms. A mass of cerumen may 

force inwards the membrana tympani and the chain of bones, until 

the base of tlie stapes is pressed against the contents of the vestibule. 

In some cases of this nature, constant attacks of giddiness occur ; in 

others, there is a confusion of ideas and an inability to walk 

■straight ; and in a third class, there is a feeling of weight and pres- 

■■nre on the head. These symptoms are often combatted by the use 

rof counter-irritants and depletion ; but the only proper remedy for 

\ tbem is tbe removal of the accumulation. 

In certain cases there is a large mass in the outer half or two- 
thirds of the tubes, while the portion near the membrana tympani 
is empty ; in others there is only a small quantity, which adheres 
to the outer surface of the membrana, and gives rise to great irri- 



THE EXTBRKAL MEATUS. 



81 



tation, and irregular action -of the tensor tj-mpani muscle. When 
the masB is very hard, it is liahle to cause inflummation of the der- 
moid meatus. A collection of cerumen may remain in the ear for 
many years, and the cars of the patient may have been frequently 
syringed without the nature of the affection being detected. Those 
accustomed to pay attention to cases of deafncBS will, however, 
generally be able to state when cerumen is present, even without 
any examination. I have frequently diagnosed the disease from 




graall; dilntcH b; ceraruen 



the written account of a medical man ; and a repetition of the 
syringing (which had previouBly been practised), but with increased 
vigor, has entirely removed the deafness. An examination with 




the speculum and n strong light should, however, always be made 
before adopting any treatment. 

The prolonged presence of hardened cerumen in the external 



THE DISEASEH OF TOE EAR. 



meatus is Bometimea productive of injury to the walls of the r 
and to the membrana tyinpani. In my museum are several speci- ] 
mens in which the osseous meatus hfl.-* been much dilated; others in f 
which the bone has been absorbed in parts ; and in one instance a/ 1 
portion of wax was imbedded in the mastoid colls, having passed I 
through an orifice in the attenuated posterior wall of the meataa. J 
In another instance, where the cerumen, by its pressure, had caused.] 
an ulcerated orifice in the membrana tympani, a portion of it had' J 
found its way into the cavity of the tympanum. 




Ccrnmen piciJMliiig through tha MsmbrsntL TfoipBDi into the TjmpBiiia Caiitjr. 



The treatment of cases in which there is an accumulation of ceru- 
men of course consists in its removal! The best, and indeed the | 
only judicious mode of effecting this, ia by the use of the syringe, 
wMeh will thoroughly clear out even the hardest masses. The uae ] 
of other instruments, as the scoop, has been suggested; but I have I 
rarely known tliem to have been used without the production of pain, ] 
inflammation, and often of discharge from the dermis. No doubt J 
the ordinary small syringe is not powerful enough to remove a hard- 
ened mass ; but the one I usually employ, and which is valuable for 1 
many other purposes, holds three ounces and a half, and is furnished | 
with two rings, so that it can b»held in the right hand, and leave j 
the left at liberty to hold the oar of the patient. 

The nozzle of the syringe consists of a metallic tube of very small j 
size, which should be made to take off until the water has been drawn J 
in through the large aperture, and then be ngain fixed on. By doing j 
this, air is kept out of the syringe and much time is saved, as it \ 
not ea.ay to fill a large-sized syringe through a small aperture. I 
The point of the nozzle should be somewhat larger than the body of J 




AL MEATUS. 



83 



ftn orilinarj- probe, bo that the water may be injected with sufficient 
force, and its return at the orifice be unimpeded. The ear of the 
patient should be brought opposite to a window, and the point of the 




Syringe sod Noii) 



BjTinge snould be placed at the poatertor part of the orifice of the 
meatus, or the stream is liable to strike against the anterior wall of 
tho tube. Whenever the syringe is used, the ear should be drawn 
backwards so as to straighten the tube ; and if thia cannot be ef^ 
fected, on account of the left hand of the surgeon being otherwise 
engaged, tlie posterior wall of the meatus may be pressed back- 
wards by the point of the syringe. Warm water alone is generally 
sufficient, without the use of any solvent. It should be quite clear; 
and it is always desirable to have two vessels ; one for the water 
before it is used, and the other to receive it when returning from 
^he ear. If a glass vessel be used for the latter purpose, ihe condi- 
tion of the water, and consequently of the ear, is more readily as- 
certained. The use of an ear-spout is very serviceable during the 
process of syringing. It consists of a spring to pass over the head, 



THE DISEASES OF THE EA 



at one end of which is a funnel tu fit under the ear, down whieh the 



water can run 



into the has 



In many cases, when the collection of wax is not very hard, the 




k 



injection of one or two ayringes full of warm water is sufficient to 
dislodge the mass ; in others, a much longer time is required, and 
when the wax has been very hard, I have sometiraes injected warm 
water for twenty minutes or half an hour without removing any 
particles, or even causing the water to he clouded. At times, it is 
well to let the wax become softened by the water before using the 
syringe again; and where the cerumen, is unusually hard, or the 
meatus so tender that the syringing causes much pain, it is desirable 
to order a weak alkaline solution to be dropped into the ear in the 
intervals. As it is not desirable to proceed with the syringe when 
there is no wax left, the meatus should be frequently inspected to 
ascertain the progress made, as the deposit frequently comes away 
slowly in small pieces ; the last portion, however, is usually large, 
and is often a cast of the membraua tympani. After the extraction 
of the cerumen, a piece of cotton-wool may be worn for a day or 
two. 



CASES OF ACCUMULATION OF CEEOMES IN THE MEATUS EXTBRNUS. 



Case I. — Mrs. R., aged 38, consulted me in July, 1804, on account 
of great dulness of hearing. She stated that, without any preyiooB 



THE EXTERNAL MEATUS 



Byinptoms, ten inoiitlis previously sbe had become smldenly deaf, 
first in one car and then in the other. After being deaf for a month, 
there was a crack in each ear, and she regained her hearing, which 
had remained perfect until within a few days, when, during a severe 
cold, she again became deaf. Upon examination, I found the meatus 
of each ear full of dark cerumen ; the hearing distance was only half 
an inch, and the patient required to be spoken to loudly within a 
yard. Upon removing the cerumen the hearing was perfectly re- 
stored. 

Case II. Maa» of cei-umen extremely hard and very difficult to 
remove. — Lord D., aged between 50 and 60, consulted me, in April, 
1851, on account of deafness in the right ear, accompanied by a 
sensation of fulness in that organ. A large mass of cerumen was 
detected in the meatus, which was not at all affected by syringing 
for half an hour. A solution of carbonate of soda in water {5j @ 3j) 
was ordered to be dropped into the ear for some days ; but the mass 
was scarcely at all softened. The application of the solution was 
therefore continued, and it was only after several weeks that the 
cerumen was dissolved sufficiently to be removed with ease. 

Case III. Accumulation of cerumen attended teit/i pain and in- 
fUtmmation of the dermis. — Miss H., aged 30, consulted me in May, 
1853, on account of a shooting pain in the right ear which she had 
experienced, with scarcely any intermission, during a fortnight. 
She was not aware that the hearing power was at all diminished. 
On examination, each meatus was found full of cerumen, the hear- 
ing distance of the right ear being half an inch ; that of the left, 
ten inches. The cerumen wos removed from each ear ; and that in 
the right was exceedingly hard, requiring frequent syringing. The 
hearing distance of the right ear rose to six inches ; that of the left 
became natural. The surface of the right meatus was red, and it 
was swollen. The pain ceased, and the symptoms of inflammation 
disappeareil, after the cerumen was removed. 

Case IV. A mass of cerumen producing infiatnmatton of the der- 
moid layer of the membrana fympani. — J. R. M., aged 55, a surgeon, 
complained, in 1849, of pain in the right ear, with much deafness. 
The pain was paroxysmal ; very acute ; and was increased during 
the aet of swallowing. The meatus was found distended with 
cerumen, the removal of which gave immediate relief to both pain 
and deafness. The upper half of the dermoid layer of the mem- 



86 THE DISEASES OF THE EAR. 

brana tympani, against which the mass of cerumen had evidently 
pressed, was red and much swollen ; the lower half was healthy. 

Case V. An accumulation of cerumen causing neuralgic pains in 
the face. — G. W. H., Esq., applied to me, in May, 1853, on account 
of a dulness of hearing in the right ear, accompanied by slight pain 
in the ear, and a good deal of pain over the right side of the face. 
This facial pain came on at times very suddenly, was very acute, 
and then disappeared : it had lasted for eight or nine days. A 
large accumulation of cerumen was found to fill the right ear : and 
when removed by the syringe, the dulness of hearing, the pain in 
the ear and in the face, entirely disappeared. 

Case VI. An accumulation of cerumen causing pulsation in the 
ear, — W. E., Esq., aged 53, consulted me, in October, 1851, on ac- 
count of a pulsation in the right ear whenever he reclines, but which 
ceases directly he assumes an upright position. He also complained 
of occasional singing in both ears. For these symptoms he had for 
some time been under medical treatment, but it had not succeeded 
in diminishing them. A mass of cerumen was found filling each 
ear, the removal of which improved the hearing greatly, and en- 
tirely removed the pulsation. 

Case VII. A collection of cerumen in the external meatus ; giddi- 
ness and other symptoms of cerebral irritation cured at once by the 
use of the syringe, — L. S. M., Esq., aged 43, consulted me in No- 
vember, 1845. He stated that, five or six years previously, he had 
an attack of deafness in the left ear, attended with a considerable 
amount of singing noise ; since that time he has occasionally felt 
deaf in the morning, but has usually recovered his hearing during the 
day, and at times, after blowing his nose, he has been deaf for a 
short time. Eleven months ago, after going into the open air from a 
warm room, a singing suddenly came on in the right ear, and has 
remained ever since. Lately he has had a sensation of weight at 
the top of the head, and frequent attacks of giddiness, which have 
caused him great alarm. While walking in the street, he has ob- 
served himself now and then to make " a lurch." Upon inspecting 
the ears, each meatus was found to be nearly full of hardened ceru- 
men ; which was carefully removed by means of the syringe. The 
symptoms immediately disappeared, and he had no recurrence of 
them. Another patient, an artist, who suffered in the same way, 
was so giddy that he was obliged to lean on the railings, and rest, 
on his way to my house. He was also unable to discern the features 



THE EXTKKNAL 



87 



of Ilia " sitter" for more than a miflute at a time, and hod tlic 
greatest difficulty in writing an ordinary note. He likowiae was 
cured at once by tlie removal of cerumou from each car. A third 
paticut was by the sauie means cared of a constant pain and numb- 
ness in the head : in a fourth, the pain had extended down the back. 
The following case is also interesting : 

Cage VIII'. Confusion m the head, inability to walk straight, 
cauxed by a collection of cerumen. — Mrs. R., aged 45, consulted me 
in April, 1845. She slated that, four months pre^-iously, she first 
began to experience noiaes in the ears, which were followed by a 
great amount of deafness. These symptoms lasted seven weeks, 
and then disappeared for three weeks, at the e:(piration of which 
time they came on again, accompanied by a sense of confusion in 
the head. This, at times, was so bad, that not un frequently, for a 
few seconds, she could not tell where she was. She has at timesi 
been so giddy, that she has reeled and fallen in the streets ; and, at 
other times, she has not been able to retain her hold of things, so 
that they have fallen from her hands. On examination, a large 
compact mass of cerumen was found in each car ; which, after some 
syringing, was got rid of; and the operation was followed by the 
entire disappearance of all the symptoms. 

In some cases, the hard mass of cerumen has pressed against the 
outer surface of the membrana tympani, with sufficient force to cause 
inflammation of its substance, and of the mucous membrane of the 
tympanum. When this has been the case, the application of leechbs 
has been required before the head-symptoms entirely disappeared: 
in other instances, they have only gradually subsided, though, as a 
general rule, they disappear with the removal of the cerumen. 



CHAPTER V. 

THE EXTERNAL MEATUS (coiitinued). 
THE DERMIS AND ITS DISEASES. 

1. ACUTB IHFLAMMATIOH : — a, ACUTE INFLAMMATION CONFINED TO THE DERMIS — TREAT- 

MENT CASES, bf ACUTE INFLAMMATION EXTENDING TO THE BRAIN AND ITS 

MEMBRANES — TREATMENT — CASES. 

2. CHRONIC INFLAMMATION : — a, CHRONIC INFLAMMATION, WITH HYPERTROPHY AND 

ACCUMULATION OF EPIDERMIS — TREATMENT — CASES, b, CHRONIC CATARRHAL 
INFLAMMATION — TREATMENT — CASES. C, CHRONIC CATARRHAL INFLAMMATION EX- 
TENDING TO THE BONE AND TO THE BRAIN — TREATMENT — CASES, d, ULCERATION. 

The diseases to which the dernm of the external meatus is 
subject are : — 

I. Acute Inflammation^ ending in resolution, discharge of serum, 
mucus or pus, or in ulceration. 

II. Chro7iic Inflammation, with or without discharge, polypoid 
growths, or caries of the bone. 



I. Acute Inflammation of the Dermis. 

This is one of the diseases hitherto comprised under the term 
otitis. The external meatus is very sensitive, especially towards 
the middle. This sensibility is due to the dermis, which is abun- 
dantly supplied with nerves and bloodvessels, and is covered by a 
delicate layer of epidermis. This membrane is liable to inflammation 
from many causes, such as the introduction of foreign bodies or 
acrid drops into the meatus ; an accumulation of cerumen ; the 
application of cold or of heat, especially when arising from sudden 
changes of temperature in the weather ; or any debilitating illness. 

The symptoms of this affection, at its commencement, are a feel- 
ing of fulness, stiffness, and uneasiness in the meatus, which is in- 



THE EXTERNAL MEATUS, 



creased when the ear is pressed uptin, or when the outer ear ia moved 
by its muscles. This sensation is followed by pain, often very acute, 
although not bo distresaing as in severe inflammation of the mucous 
membrane of the tympanum : throbbing and singing often accom- 
pany the pain, and there is Bometimes a diminution of the power of 
hearing. The latter symptoms are probably due to congestion of 
the middle and internal ears. With these symptoms there is gene- 
rally a quick pulse, feverishness, and restlessness; and the pain 
sometimes extends over the side of the head. On examination in 
the early stages, the dermoid meatus is seen to be red, its blood- 
vessels being apparent through the cpidennis. This redness some- 
times extends to the dermoid layer of the mcmbrana tympani, the 
vessels in the circumference of which become enlarged. Should the 
affection advance, the dermis becomes tumefied, so as to diminish 
the calibre of the meatus one-third or one-half, and the pain increases. 
In some cases, these symptoms subside without the formation of 
matter ; in others, a copious secretion suddenly takes place, and is 
followed by such immediate relief that the patient thinks an abscess 
has burst. E.xamination, however, reveals the real condition of the 
meatus. The discharge filling the meatus having been carefully 
removed by the syringe, the surface of the tumefied meatus is seen 
to be of a deep red color, wholly denuded of epidermis, and in its 
place secreting a mucous fluid. In the severe forms of this inflam- 
matory action, this secretion consists of mucus, which comes away 
from the ear as a largo mass of viscid white matter, somewhat 
analogous to that secreted by the mucous membrane of the tympanum 
in eases of catarrh ; the difference being, that in the case of mucous 
from the tympanum, the circumference of the mass is more fila- 
mentous, the color not so white, and the substance less consistent. 
After this discharge has continued for some days, it loses its viscidity, 
and becomes milky, remaining so as long as the affection continues to 
he chronic. Wlien the inflammation ia not very severe, the character 
of the secretion is always milky, not mucous. There are cases in 
which the secretion is thin, and nearly as transparent as serum ; at 
times it is tinged with blood. The quantity of this serous secretion 
astonishes both patient and medical man. I liave never bad the 
opportunity of collecting the secretion, so as to be able to form a 
correct estimate of the quantity effused in twenty-four hours ; but, 
judging from the saturation of handkerchiefs, linen, and pillows, it 
muBt amount to several ounces. The source of tliis large quantity 



90 THS DISEASES OF THE EAR. 

of Bocrption b the bloodvessels of the dermoid meatus, which 
extremely numerous, and very large. 

Some palieiils are flubject to frequent attacks of scute inflamma^ 
lioD of the meaiua, but in them the symptoms are not very severe • 
io others, however, the inflammation extends to the bone, and thence 
to the membranes of the Itrain. It is not uncommon to see patients 
in whom there we some symptoms of cerebral irritation, though not 
of a serious character; while, iii other instances, they arc bo for- 
midable as to destroy life. These cases will hereafter be more faUy 
deftcriUnl. 

Acute inflammation of the dermoid meatus sometimes occurs from 
injury, but it usually subsides under the use of leeches and fomen- 
tations. 

The treatment of acute infiammation of the dermoid meatus con- 
sists, in the milder cases, of the application of evaporating lotions. 
or of hot fomentations and poultices; in the more severe, leeches 
should be applied to the margin of the orifice of the meatus, so as to 
remove the blood directly from the congested vessels; and the 
BMstDS itself should be syringed with hot water, the head beinit 
slightly raised. The patient should be kept in bed, perfectly free 
from all noise, and small doses of opium may be administered. After 
the disappearance of the pain, the ear is to be washeil out thorouglily 
with warm water, three or four times, or oven ofteuer, daily; so as, 
10 the first pUce, to insure the removal of the whole of the di». 
charge, which is apt to eausc irritation, and, in the second place, to 
act as a warm bath to the inflamed membrane. Unless there is con- 
stttutional debility, or the ear has been weakened by previous dia- 
eue, the discharge nsually ceases in the course of a few days ; the 
epjdennis is again naturally secreted ; and the power of hearing re. 
tuns. Cases of acute inflammation of the dermis depending upon 
emifltitutiunal caueea, and nsually following nervous e.xcilement, re- 
qaire to be treated by tonics in uldition to the local applications. 
lasoiM Cjuc»< however, foundation is laid for chronic catarrhal i&- 
II of the dermis, of which 1 shall presently speak. 




Ca»e. I, Antte imjlammation of the tiertuoid mtatug, arUiiii/ from 
cold. — M. F., £14., aged 26, a medical man, consulted me in January, 



J 



TUE EXTERNAL 



91 



1853, on account of great jiain id eacli car. lie said that fourteen 
days previously, after being wet througli, lie had an attack of violent 
pain in bolh ears, — but especially in the left: after twenty-four 
houre' pain, discharge appeared and relief ensued. The day before 
consulting me, during a journey, pain was again felt in each car, 
but more particularly in the right : at times the pain was greatly 
ajjgravated. On examination^ the dermis of each meatus was seen 
to be very red and swollen; the epidermis was absent, but there was 
no discharge. The hearing distance of each ear was eighteen inches. 
An evaporating lotion was applied on cotton-wool, and the affection 
subsided. 

Ca»e II, Aetiie inflammation of the dermis ; copious xecrntion of 
muejis. — Miss M., aged 17, tall, and rather delicate, consulted me, 
December 20, 1863, on account of pain in the right ear, accompanied 
with discharge. 

History. — Ten days previously she felt a slight pain in the ear, 
which gradually increased so as to interfere with her rest at night. 
This continued for eigbt days, though better at times. Two days 
previous to seeing me, a discharge appeared from the car, and has 
continued. 

On examination, the meatus was seen to be filled with tliscbarge, 
which, when removed by the syringe, was found to consist of a large 
white mass of mucus, about the size of an ordinary horse-bean, and 
of scales of epidermis. The membranous meatus was much tume- 
fied, its surface being red ; the dermoid layer of the membrana tym- 
pftni was also red and swollen. The hearing distance was only eight 
inches. 

Treatment. — Two leeches were applied to the orifice of the meatus, 
which was syringed out with warm water twice daily. Tlie pain 
gradually subsided, and in sis days tbe discbarge bad disappeared. 

Ca»e III. Acitte inflammation of the dermic; great deafneM, aiu? 
copious secretion of semm. — A. H. H., Esq., aged 38, of a weakly 
constitution, sent for me in January, 1854. 

Hintnry. — For three weeks be had been suffering from an attack 
of inflammation of the lungs, and four days previously, when becom- 
ing convalescent, was seized in the night with a violent pain in the 
left ear. This, in spite of treatment, lasted for about twelve hours, 
wbcn a sudden burst of discharge took place from the ear, which 
much diminished the pain. When seen by me on the fourth day 
after the discharge had appeared, there was still great sensitiveness 



"• TBI DISEASES OF TOE EAR. 

*■ tfce acBtas, aad mt grmt aa amooot of dafuesa, tlut the wmtdi 
**• »« Imnl ercB wWit in moUct with the ear, Ob <Tamiiuttian, 
the densia was fond swoHcd and red, and the dermoid lajer of th« 
■^braiM t^npaai in the same state. So copious was the secrptkn 
of wnoK, that in half aa hour ■ white handkerciiier was pcrfretly 
■««»ed with it. Great fear w« felt lew the ear shooW have been 
*^<™»*y injured hj the inflaauoatioD ; Iwt finding ihai the mem- 
■'■»• trmpau stood oat natorallr, and fecJing (hat congestion of 
•J^psnic mocons membrane was qaiic sufficient to produce the 
***■">«*. hopes were held oat that the bearing woold return as soon 
M tie congestion sabeided. A leech was ordered lo be applied to 
the inar^ of ti,^ orifice erery eecood day : the meatus was srringed 
It With Warm water twice daily, and slight resication was nsed nt 
"** back of the ear. In the coarse of three days the discharge ti«gnn 
to subiiidc. the pain ceased, and at the end of ten days the hearing 
**" "^stored. 

C'aa^ IV. FrrqunU attaeit of infiammatum of the drrmit ; A^or- 
t^powtr tutMntl. — Miss C, aged 28, consnlted me on March Tth. 

BitUry. — Daring two years has been subject to attacks of pain 
ID each ear, followed fay discharge, after which there has been ma 
mtolerahle itching. Three months ago, she ?uffere<] from one of 
these attacks of pain, since which she has had a c^mstant irritatiott. 
On '""'i ii rf i ' i II , the dermis lining each meatus was observed to be 
red and awoOea- The hearing disUnce of each ear was natural. 
By 'PpfytBC te«ehes to the maigin of tiie orifice of the meatus tb« 
imtaliog ajDiptoma disappeared, and the recurrence of the attacks 
of iiifliBMBliim was preTcnte<l. 

tevn crrLAiauTiojc of the DEEUVID HZATVS ESTBNDIXO 
TO THE BRAIX. 

Amatomiml titerratunu. — Tho bloodvessels ramifying throagh 
tbBBHahnaoaa meatus arc directly continoous with tho«t.> eulering 
Md MBphioK the uwiiiian meatas ; the intimate connection betweea 
At jfT MM of th* mcntna and the bone is therefore very obvious. 
Dw T f t **«— of tlw i—fnai walls of the external meatus to the 
MvitT of the craaimn are deserriDg attention. In the adult, it will 
be fowwl that the nppn- vail of the meatus consists of a solid 
■ jHHia af booc, Taryimg from a line to two lines in ihickuess. wbidi , 



THE EXTERNAL MEA 



separates the cavity of the meatus from that occupied by the iniildlc 
lobe of the cerebrum. In some cases, a prolongation of the tym- 
panic cavity is found extending into the substance of the upper wall 
of the meatus. In the child, these relations differ remarkably from 
those juat detailetl. At birth, and for- the first year subsequently. 
the only rudiment of the osueous external meatus is the superficial 
depression situated in the middle of the outer and lower part of the 
pars squamosa, immediately posterior to the root of the zygomatic 
process. This depression, to which the name "fossa auditoria" may 
be appropriately applietl, has the rudiments of the mastoid process 
posterior to it ; its surface is smoother, and its substance denser, it 
also contains fewer foramina for the transmission of bloodvessels, 
than the siirrounding bone. At the period of birth, the portion of 
bone forming the fossa is not more tiian half or three-quarters of a 
line thick, and the membranous meatus is attached to tlie outer, the 
dura mater of the middle cerebral cavity to the inner surface. Its 
structure is far from being compact or dense, and in its substance 
the bloodvessels from the meatus communicate with those of the 
dura muter. 

As the bone approaches maturity, the fossa assumes an oblique 
position, and forms the upper wall of the external auditory meatus, 
while it is separated from the cavity of the miildle cerebral fossa by 
a dense layer of hone, into which cells communicating with the tym- 
panic cavity are not unfrequcntly prolonged. In the adult, the 
fossa auditoria has nearly lost its oblique direction, and become a 
horizontal lamina of bone. 

From the foregoing remarks, it will be evident that disease of the 
membranous meatus externus is liable to extend to the outer surface 
of the bone, and thence to the interior. In the only case of fatal 
chronic disease which has fallen under my notice, the disease ad- 
TSDced, posteriorly, to the lateral sinus. 

Acute injlammation of the dermoid vieatus may arise from the 
application of cold to the ear, or from the irritation of a foreign 
body : but neither cause is usually sufficient to produce extensive 
inflammation of the brain or its membranes, unless considerable con- 
stitutional irritation coexists. 

For the particulars of the following case I am indebted to Dr. 
Nairnc, who gave me the opportunity of dissecting the ear. 

Cage V. Acute injlammation of the dermis of the external meatuB, 
extending to the brain and i(t mcmbraneB, cautcd by picking the ear 



94 THB DISEASES OF THE EAR. 

with a pin. — Mary Wells, a single woman, aged 24, of a scrofulous 
family, was attacked on the Ist April, 1841, with severe pain in the 
right ear, which for some hours was distractipg, and was followed by 
a sensation of something bursting, and by a discharge of blood and 
water, that aflforded immediate relief. She had, prior to this, suf- 
fered no pain, and could only account for what happened from 
having picked her ear with a pin, to relieve a tingling in it. The 
discharge was mixed with blood for two days, and ceased entirely at 
the end of the week, when she felt pretty well. In a few days, 
however, she had a rigor, followed by violent pain in the ear, which 
lasted twenty-four hours, when a copious purulent discharge took 
place, giving relief as before. She was now free from pain, and felt 
in good health. The discharge continued profuse until the 24th of 
April, when it again ceased. The next day she was seized with 
violent pain in the right ear and side of the head, accompanied by 
vomiting and symptoms of general fever. As the bowels were con- 
fined, she was purged. On the 28th, the pain in the head returned 
with great severity, and towards evening extended towards the right 
ear, unaccompanied with pain or redness, or increase of pain on 
pressure. She vomited twice. Ever since the first attack, the 
hearing on the right side had been affected, and during the last few 
days she had complained of noise in the ear and giddiness, and car- 
ried her head bent backwards.^ The pain increased, and on the 30th 
she was admitted into St. George's Hospital, and ordered a calomel 
pill and haustus senme. 

On the 1st of May, her state was as follows : — Pulse 104, full, 
sharp, and compressible ; tongue red and glazed ; the skin hot and 
dry; the conjunctiva slightly injected. There was slight intolerance 
of light, and a peculiar sensitiveness of the sense of touch, so that she 
shrank from the approach of a finger, though, when touched, she felt 
no pain. Her eyes were bright, and in constant motion ; the right 
pupil was a little more <lilated than the left. The respiration wag 
quick (thirty-two per minute). The countenance was placid, though 
the manner was rather hurried. The catamenia were present. She 
was cupped, had cold lotion applied to the head, and calomel and a 
black dose were administered. During the following night she was 
delirious, though the senses could be recovered by an effort. 

May 2d, 1 p.m. — There was a slight degree of opisthotonos this 
morning, and the nurse remarked that, on her getting out of bed, 

* Mr. Maule, who saw the patient two or three times, was of opinion that an abscess was 
forming in the internal ear. 



THE EXTERKAL MEATUF;. 



05 



there wns n peculiar rigidity of the muscles. She was, however, 
quite comfortable, ttnd said thikt the headache went away about an 
hour after the cupping. Pulse 1'20, sharp but compressible ; tongue 
red and glazed. She was ordered a blister behind the right ear, and 
three grains of hydragryrum oum cret& were administered night and 
morning. 

3(1. — The feverish symptoms were somewhat abated, and she had 
some quiet sleep in the morning. The urine passed in natural quan- 
tity. 

4th, 1 P.M. — Pulse again sharper, though the tongue was moist. 
The eyeballs were tendi-r and suffused. No pain complained of, but 
she moans on being moved. The countenance is depressed, and she 
throws the clothes off her; she is, however, quite sensible when spoken 
to. Ice was ordered to be applied to the head. To proceeil with 
other medicines. 

3 P.M. — Is heavier and less sensible, 

6 P.M. — The ice was applied about 4 o'clock, soon after which she 
went into a comHtoso state, occasionally, however, waving her hands, 
and appearing to recognize her friends. 

5th, 11 A.M. — Became perfectly comatose about 4 A.M. She is 
now perspiring profusely. Pupil of right eye contracted. She 
died at 12. 

DUgectfon of the body twenty-six hour* after death. The weather 
warm. Mead. — There were a few patches of lymph upon both 
hemispheres of the brain, immediately beneath the arachnoid, which 
was more vascular than natural. The convolutions of the brain 
were flattened and its substance was watery, but not soft, with the 
exoeptioQ of the corpus eallosum, fornix, and the parts contained 
in and near the lateral ventricles, which broke up easily on a slight 
touch. The cavities of the ventricles were large, and contained a 
quantity of turbid fluid. The pons Varolii, medulla oblongata, , 
and adjacent nerves were smeared with concrete, purulent lymph, 
effused into the cavity of the arachnoid. The cellular tissue around 
the optic nerves and their union, contained pus. The cerebellum 
was somewhat softer than natural. The dura mater covering the 
surface of the petrous bone was very vascular, and its vessels were 
distended with blood ; it was also separated from the bone by a 
small quantity of serous fluid. The substance of the bone was of a 
dark color, its bloodvessels being distended. On examining the in- 
ternal ear, the raembraua tympani was found to be entire, but both 



THE DISEASES OF THE 



it and ttie mucous membane lining the tympanic cavity were more ' 
vascular than natural. The chief disease was found in the external 
meatus, of which the membrane lining the inner third was soft, 
highly vascular, easily detached from the bone, and covered by 
purulent matter. There was no appearance of ulceration on the 
surface . 



11. Chronic Inflammation of the Dermis lining the Meatdb. 

This afiection may be divided into — 
[a.) Simple Chronic Inflammation. 
(fi.) Chronic Catarrhal Inflammation. 



(ff.) Simple curonic inflammatiox. 

This foi-m of disease, without discharge, is frequently met with, 
and is often associated with a declining state of health, though it 
occasionally occurs as a purely local affection. One of the most 
common predisposing causes is residence in a moist atmosphere. In 
some very obstinate cases, change of air 1ms been requisite before 
the affection coidd be abated. The exciting causes appear to be the 
same as those of acute inflammation, viz., the application of cold, or 
of any irritating substance to the meatus ; perhaps the most common 
exciting cause is the habit of picking the ear with some foreign body. 
The symptoms of chronic inflammation are a feeling of distention in 
the ear, often coupled with slight pain, or with an intense itching. 
Sometimes the dermis is tumefied, so that the canal is diminished to, 
one-half, or eVen to one-fourth of its natural size. In other cases, 
the dermis is scarcely at all swollen, but its free surface is red, and 
the epidermis is thrown off in large flakes. These flalces of epidermis 
accumulate and fonn large masses, which consist of several layers, 
and these masses are apt to block up the meatus, and produce s 
serious diminution of the hearing power. Occasionally this epider- 
mis collects in such large masses as to dilate the meatus, or to cause 
disease of the bone ; in other instances, it produces acute inflamma- 
tion of the dermoid meatus, and of the dermoid layer of the menw 
brana tympani. 

Treatment. — Wlien there is hypertrophy of the dermis, withoDt 
much tenderness, a solution of nitrate of silver (3j @ gj) may be 
applied twice a week ; and slight counter-irritation be kept up at 




THE EXTERNAL 



97 



lEe aome time over the maatoiil pioceas. If the surface of the dermis 
is denuded of epidermis in parts, and more vascuhir than natura], 
the meatus should, in the first place, be syringed with warm water, 




tbx Torm of « tabular oul-d«-j 



in order to remove all the particles of epidermb which are apt to 
cause irritation, and at the same time soothe the dennis. While the 
syringing is being carried on, an astringent lotion may be applied, 
on cotton-wool, to the surface of the meatus. After the inflamma- 
tory symptoms are subdued, a weak solution of nitrate of silver 
(gr. X. @ Sj) may be applied twice daily. Should the epidermis 
continue to collect within the meatus, it must be removed by the 
syringe, which is generally snlBcicnt for that purpose, notwithstand- 
ing that the removal of masses of epidermis, on account of its den- 
sity, and the close way in which one layer folds within another, re- 
quires considerable patience. 



L 



Case I. Simple chronic inflninmation of the dermoid meatus. — R, 
P. A., Esq., aged 47, in good health, consulted me on July 4, 1853. 

Sittort/. — During the last year and a half, he has suffered at 
times from extreme itching, with dulness of hearing, followed by 
slight discharge. Upon examination, the meatus of each ear, near 
the orifice, was fonnd to contain a large quantity of soft cerumen ; 
at the middle part the dermis was of a deep red color, and the blood- 
Tessels were enlarged and tortuous. The hearing distance with the 
right ear was eighteen inches ; with the left, seven. 

Treatment. — Each meatus was washed out with half a pint of 
warm water, twice daily; and at night a lotion, consisting of a 
solution of chloride of zinc in water (gr. ij @ 3j), was applied on 



»0 THE DISEASES OF THE EAR. 

cotton-wool to eacli meatna. In tlie course of a fortnight he 
quite cured. 

Case II. Simple chronic infiammation, with detquamation qf ths 
ejpidcrmii. — Miss E. P., aged 39, in a somewhat debilitated etate, 
consulted me on July 1, ]853. 

Siitory. — During the last two or three winters, after attacks of 
cold, had suffered a good deal of pain in each oar, accompanied bjr 
deafness. The pain remains for two or three days, then a skin 
comes away followed by relief to the pain, and improvement in the 
hearing. Six months ago had a very bad attack, succeeded by dis- 
charge, which continued for a few days. During the last three 
years has suffered from considerable irritation in the ears. On 
examination, the meatus of each ear was found red in parts — a red- 
ness that, on the left side, extended to the dermoid layer of the 
membrana tympani. Portions of epidermis adhered to the sur- 
face of the dermis; and when these were removed, the dermis waa 
quite denuded. The bearing distance of the right ear was three 
inches ; of the left, one inch. 

Treatment. — Two leeches were applied to the margin of the 
orifice of each meatus ; warm water was syringed into each ear twice 
daily ; and, when the congestion was diminisbed, a solution of nitrate 
of silver in water {gr. v. @ 3j) was daily applied to both. A email 
portion of vesicating paper was also applied over each mastoid 
process, and tonic medicines were administered. This treatment 
afforded great relief; and when I saw the patient again in Decemberj 
the hearing was very much improved, and there was an abundant 
secretion of cerumen in each ear. There had been one attack in 
the left ear in the month of August. 

Caae III. Oironic inflammaiion of the dermis, with great hyper- 
trophy. — -Wiss T., aged 57, in tolerable health, consulted me in 
January, 1853, on account of great irritation and deafness in each 



—During the last five or six years has had attacks of 
deafness, accompanied by a considerable swelling in each ear. When 
the swelling decreased, the hearing power partially returned. About 
three weeks ago felt much irritation in both ears, accompanied, at 
times, by pain and much dulness of hearing, but not by discharge. 
On examination, each meatus was discovered to be so tumefied that 
the tube would only admit an ordinary sized probe ; the surface of 




THEBXTEBNALMEATL'S. 99 

the dermia was of a plum color : the watch was not heard, except 
when pressed on the ear. 

Treatment. — Leeches were ordered to be applied to the orifice of 
each meatus, and to be followed by the use of a solution of nitrate 
of fiilver (5ss @ 3j)- I did not hear the result. 

Ca»c IV. Chronic inflammation of the dermoid meatus ; accumu- 
lation of epidermis. — The Rev, G, T., aged 55, consulted me in July, 
1850, on account of pain in the left ear, with accompanying deafness. 

History. — During several months has had a tenderness in the left 
ear, with a sensation of fulness, and a diminution of the hearing 
power: latterly these symptoms have increased. On examination, 
the surface of the outer half of the meatus was observed to be red, 
and somewhat tumo&ed, and tho inner half was completely full of 
epidermis. Hearing distance with the watch, two inches. 

Treatment. — The collection of epidermis was removed by the 
syringe and warm water. This operation, however, required the 
greatest care, on account of the extreme tenderness of the surface 
of the meatus ; even the ordinary stream of water from the syringe 
being productive of great pain. After the removal of the collection, 
the hearing power was greatly improved. The surface of the dermis 
being red, a weak solution of nitrate of silver was applied to the sur- 
face of the meatus twice a week, which effected further improve- 
ments; hut the epidermis again collected. After its removal, mild 
astringents were used, and the ear was syringed frequently with 
warm water, which diminished the inflammation, but the epidermis 
still continues to collect, and requires removal by the syringe every 
two or three months. The moist atmosphere in which this patient 
lives, is probably a cause of the unyielding character of the affection. 

(6.) CUEONIC CATARRHAL INFLAMMATION OP THB DERMOID 
HBATCa. 

This disease has been frequently classed among the cases of otor- 
rhoea. As its name implies, it consists of chronic inflammation of 
the dermoid meatus, with accompanying discharge. In many in- 
stances, the disease is confined to the meatus ; but in others, it 
advances to the dermoid layer of the mcmbrana tympani. It most 
commonly occurs in children ; though by no means rare in adults. 
In childhood, it is usually accompanied by a tendency to glandular 
enlargements or some other sign of constitutional debility. In the 
sdolt, it is also too often symptomatic of a depressed state of health. 
The exciting cause may be an attack of acute infianunatton of the 



100 



THE DiSEA^ES or TBE EAR. 



k, aa hiJBrT, llie ose of Minalstiog applleatkna, or 
■cmIck, KarUtina, or caurrii. Often thia dlectioB bas 
able casK, sdiI appesn with a ali^t itduog in the eu- ; 
JBJtei, tbe ap|i«sruic« of dudtarge ia the trst iadicattoD 
aedoa. Ia the earlj suges, there b osnallj bat Utile 
of (be power of bearing, eren irhen tbe inflanuDatton i 
tropfav extend to ibe dermoid Isrer of the membrana tjmpaai. 
When ibe iite^f* has remained for ^«me time, the roncoos men- 
brane of tbe rympaaam ia apt to participate, and deafness to reealt. 
It must, howerer, be borne in mind, that catarrh of the dermoid 
meatne, and of the dermoid layer of the membrana tympani, are 
freqnentlj lymptomatic of irritation within the tympanic cavity, 
and that ibeoe exterior symptoms cease as soon as the internal irri- 
tation is overcome. In these cases of tympathetie catarrh of the, 
dermoid mcatos, there is usoally a history of previous irritation in 
tbe ^npaoum, and mnch dalnc»s of hearing commonly precedes tbe 
appeftnutee of the discharge. After this affection has persisted some 
time, tbere is often a great degree of irrttation in tbe meatus ; sone- 
drnea there is pain, and now and then a discharge of blood. Tbe 
latter i^mptoin, however, is more common where a polypus is pr»- 
wnt. 

On txaminaiion of cases of catarrh of the dermoid meatus, tbe 
deraia ta generally found thicker than natural ; sometimes so much 
M as nearly to close the tuV/e. While in some cases the eur&oe 
(denuded of epidemus) is red. in others it is blanched. The dis- 
charge has OBDally a very offensive odor ; and its hue varies from 
milky white to dark sinte color. The peculiarity of this dischargs 
ia, that whatever may be its quantity, color, or consistence, thero 
are oo niindrn of mucus floating in it : but it mixes freely with 
water, producing a general opacity. In cases, however, in which ft 
polypus coexists with this form of inflammation, the discharge con- 
tains flocculent mucus, as also in cases of ulceration of the fihroos 
tamiiue of the membrana tyropani : sometimes there is also discbargtt 
of blond. When chronic catarrhal inflammation extends to the der- 
moid layer of the membrana tympani, the structure of this mem- 
brane, like that of the dermoid meatus, becomes liypertropbied, and 
often much congested ; tbe membrane itself loses both its nataral 
color and form ; its outer surface is flattened ; while the processus 
longiu, and frei|uently tbe processus brevis, are completely con- 
cealed by it. 



I 



THE EXTERNAL MEATUS, 101 

The trcatvient of chronic catarrh of the dermoid meatus consists 
in the efficient and frequent use of the syringe and warm water, to 
thoroughly remove the discharge, and cleanse the tuhe. Should 
there he symptoms of pain or irritation, one or two leeches should he 
applied to the margin of the orifice of the meatus, and be followed 
by the use of warm fomentations, steam-baths, or poultices. On the 
disappearance of the irritntion, weak astringent injections may be 
used, and slight counter-irritation be kept up over the mastoid pro- 
cess. These measures, coupled with the administration of tonic 
medicines, and attention to the general health, will frequently put 
a etop to the aJTeclion. In more obstinate cases,, it is requisite to 
keep up a discbarge over the mastoid process by means of vesication 
or croton oil liniment : a solution of nitrate of silver (10 to 40 grains 
to the ounce} should also be applied to the surface of the meatus 
every third day. Some cases, in spite of all remedies, are but 
slightly ameliorated, after two or three months' treatment ; it is, 
notwithstanding, of great importance that the treatment be perse- 
vered in to prevent the supervention of caries of the bones, ulcera- 
tion of the mcmbrana tympuni, and the development of polypus. 

Case V. Chronic catarrhal inJlammatwH of the dermoid vieatas 
during U-Hhing. — J. A., aged nine months, pale, and weakly, was 
admitted under my care at St. Mary's Hospital, in November, 1854, 
on account of an offensive discharge from the left ear. 

History. — The mother stated, that about two months previously, 
■when the child was irritable and restlosa from teething, a discharge 
took place from the left ear. Small at first, the quantity had gra- 
dually increased and become very offensive. 

On examinatimi, the left external meatus was seen to be full of a 
white milky discharge, that, when the ear was syringed, mixed with 
the water, which became opaque and milky, and masses of epidermis 
floated ; but there was no appearance of mucus. After the discharge 
had been removed, the calibre of the tube was observed to be dimi- 
nished one-half by the swelling of the dermis, whose inner surface 
was denuded of epidermis and somewhat redder than natural : the 
dermoid layer of the membrana tympani was flat and white. 

Treatmenf. — Dally exercise in the open air was ordered, and cod- 
liver oil administered. The surface of the body was to be sponged 
daily with tepid water, and the car to be syringed out with warm 
water twice daily, and a solution of chloride of zinc (one grain to an 
ounce of water) to be applied on cotton to the tube of the ear during 



102 



the night. The health of the child soon greatly improved, the quan- 
tity of discharge diminished, and, in six weeks, entirely ceased, 

Gum VI. Catarrh of the dennig in both ears of a child, causing 
dubmgg of hearing. — Master E. M., pged three years and a half, 
ivas hrought to me on April 6, 185.5, on account of a discharge from 
the ear, with dulness of hearing. He vaa pale and thin, his general 
health not good, and he was subject to enlargements of the cervical 
glanda. 

History. — About two years proiouBly, without assignable cause, 
a discharge suddenly flowed from the right ear, and after another 
month the left ear was similarly affected ; the discharge being abun- 
dant and the odor very offensive. After continuing for three or 
four months, the discharge disappeared from both ears ; but aboat 
a month before consulting me, it Lad reappeared with the same symp- 
toms as at first. 

On examination, each meatus was found full of milky discharge, 
and red on the surface : the substance of the dermis swollen. The- 
dermoid layer of the mcmbrana tympani was red and thick. The 
hearing power was so diminished that he required to be loudly spoken 
to at the distance of two yards. The watch was unheard except 
when in contact with the right car, or when pressed upon the left. 
It was evident that iuflammalion had extended to the tympanic 
cavity as well us to the membrana tympani. 

Treatment. — Both ears to be washed out with tepid water thrice 
daily, and afterwards to be syringed with a solution of acetate of 
zinc (five grains to the ounce) ; a portion of vesicating paper to bo 
applied over each mastoid process every second night, and two tea- 
spoonfuls of steel wine to be given twice daily. This treatment in 
two months produced considerable benefit, the quantity of discharge 
diminished, and the power of hearing improved. This improvement, 
however, did not continue, and at the end of the year I saw him 
much in the same state as when first brought to me. I then found 
that the syringing had been very imperfect, a large quantity of dis- 
charge being left in the ears after the operation. Strict attention 
to this point was enjoined ; a solution of nitrate of silver (gr. x. @ 
5j) was applied to the surface of the dermis by means of a camel's 
hair pencil, uight and morning ; the vesicating paper was again used, 
and cod-liver oil prescribed. This treatment having been puraueci 
for three months, the discharge had ceased, although the power of 
hearing was not wholly restored. 





THE EJ.TEHSA.L 



Case VII. Chronic catarrhal inflammation of the dermis: great 
irritation. — Mrs. A., aged 30, consulted me in August, 1856. She 
was in tolerable health. 

Hietory. — Two years previously she experienced at times great 
irritation and pain in the tube of each ear, followed by diBcharge : 
thinlcs the affection was caused by residence in a damp house ; it 
was aggravated by exposure to cold air. Since the above period 
has had several similar attacks, and the ears are never quite free 
from itching and discharge. The power of hearing has not been 
diminished. 

On examination, the surface of the dermis in both ears was found 
denuded of epidermis, red, slightly tumefied, and covered by a mu- 
cous discharge. Each membrana tympani was healthy. The hear- 
ing was natural. 

Treatment. — As there was evidently much congestion, two leeches 
were applied to the margin of the orifice of each meatus, and both 
cars syringed with warm water twice daily. In the course of a week, 
the congestion having much diminished, a solution of nitrate of silver 
(gr. vj @ 3j) was applied to the surface of each meatus by means of 
a camel's hair brush, twice daily. Under this treatment, and the 
occasional use of the syringe with warm water, the irritation sub- 
sided and the discharge disappeared. The affection, however, was 
slightly reproduced by a continuance of damp weather, or a reduc- 
tion of the state of health; but speedily subsided under treatment. 

Case VIII. Chronic catarrh of the meatus extemus after scarlet 
fever, accompanied by pains in the head. — E. D., aged 7, was ad- 
mitted under my care at St. George's and St. James's Dispensary 
on the 24th February, 1845. At three years old, he had an attack 
of scarlet fever, followed by ear-ache an.d discharge from each ear : 
after every attack of pain, discharge appeared. At present, and 
for the last two years, has complained of pain at the back of the 
head. On examination, the membranous meatus of each ear was 
found red, thicker than natural, and pouring out a milky secretion. 
Each membrana tympani was opaque, and its dermoid layer thick 
and vascular. The treatment consisted in the frequent use of the 
Bjringe and warm water, the application of a leech now and then to 
the margin of the orifice of the meatus, and tonic medicines. At 
the end of ten weeks under this plan the hearing greatly improved, 
and the symptoms of pain in the head disappeared. 



104 



THE DISEA 



OF THE EAR. 



(e.) Chrosic catarreal ixflammatios of the dermoid ICBA- 

TD8 EXTKNDINO TO THE BRAIN. 

It ia not common for cbronlc catarvlial inflamraation to extend to 
the bone snd the brtiin ; at least I havo met with but one veil- 
marked case, in which death was the result. 

Caae. IX, Catarrhal injlammation of the dermoid layer of the 
external meatut, with carit-g of the posterior wall ; disease extending 
to the lateral sinus and cerebellum. — Harriot Baker, aged three 
years and a half, was admitted under my care at the St. George's 
and St. James's Dispensary, on the 6th December, 1848. Her 
mother stated that the child had always been sickly ; and at five 
months old a thick creamy discharge had been seen to ooze from 
the left ear, which, thongh not abundant, was very offensive. The 
child had not till recently complained of pain, but now and then 
asked to have the ear picked, because of its itching. Three weeks 
ago the discharge ceased, violent pain ensued in the ear, with a 
swelling over the region of the mastoid and squamous processes, 
which caused the ear to project from the side of the head : great 
restlessness and delirium followed, and she waa constantly throwing 
herself about. 

On examination, the surface of the dermis was red and denuded 
of epidermis; it was smooth but not ulcerated, and much thicker 
than natural, so that the cavity of the meatus was only one-third 
of its proper calibre. The membrana tympani was absent. The 
abscess behind the car had opened; and about a wine-glassful of 
pus, of a moat offensive odor, having been discharged, the sur- 
face of the squamous and mastoid processes was felt to bo rough 
and carious. Linseed-meal poultices were applied. 

Dec. 9th. — The discharge continues very copious ; the pain and 
tumefaction have extended to the temporo-maxillary articulation, eo 
that the jaw can be opened but a very little way. 

14th. — The discharge, lately so abundant, has now ceased, while 
the pain and restlessness have greatly increased ; the hands hare 
been kept apphed to the head. 

The head-symptoms continued to increase till the 29th, when the 
patient died in a state of great emaciation. 

Post-mortem inspection. — On removing the calvarium, the dwa 
mater appeared healthy, as well as the arachnoid and pia mater. 
The lateral ventricles contained about half an ounce of perfectly 
clear serum. Upon the removal of the cerebrum there was no ap- 




THE EXTBBNAL 



106 



pearanco of disease ; the dura mater and arachnoid covering the 
upper part of the left petrous hone were quite healthy. When the 
tentorium was removed, the !eft Iiemisphere of the cerebellum was 




The Internal SurTutB of the Teinporal Bone, showing the two orifiaei in Ihe Luteral Sinus 
Wlticb were filled b; Ihe cerebellum, und also ehowing the Mrioui Sulcua tiiteralii. 

obsen'ed to be much Hofter than natural, and the portion in contact 
with the posterior surface of the pars petrosa was dark in color and 
very soft. Upon gently drawing it backwards, it was found to be 
applied against two orifices in the posterior part of the lateral sinus, 
ftnd to be separated from the cavity of the sinus by the thickened 
arachnoid and pia mater. A considerable vessel in the pia mater, 
opposite the orifice, was disfended by a firm and dark coagulum, 
half an inch in length. The anterior membranous wall of the 
lateral sinus was absent ; the bone forming the sulcus lateralis in 
the mastoid process was carious, and the sinus full of a dark-uolored 
coagulum and purulent matter ; pus was also found in the jugular 
raaa. 

The ear. — The dermis lining the whole of the external meatus 
was soft, tumefied, and dark-colored, and its surface was devoid of 
epidermis ; beneath it, posteriorly, was purulent matter, which sepa- 
rated it from the carious bones. The membrana tympani was absent ; 
but there was no more appearance of disease in the tympanic cavity 
than might have been produced by the affection of the meatus. The 



106 



THE DISEASES OF THE BAR. 



bone was carious anteriorly as far as the root of the zygomatic pro- 
ceBS and the fossa for the articulation of the lower jaw ; superiorly 
and posteriorly, the caries extended for the distance of an inch and 




a quarter, nearly to the margin of the parietal bone ; but in some 
parts the externa! table only was affected, while in others it ex- 
tended to the diploe and thence to the internal tabic. On holiUng 
the bone up to the light, small orifices were seen through it ; so that 
its external surface, or that part which was covered by the mem- 
branous meatus, was directly continuous with the lateral sinus. 

The progress of the disease in this case from without inwards, is very 
remarkable ; for there is no evidence to prove that the disease origina- 
ted elscvfbere than in the meatus ; and^t is apparent, from the direct 
communication by bloodvessels between the membranous meatna 
and the bone forming the lateral sinus, that disease could easily be 
transferred from the inflamed meatus to the bone beneath. Careful 
consideration of the subject has, however, induced me to believe that 
the progress of disease from the meatus, inwards, to the internal 
sinus and cerebellum, is of rare occurrence ; and to think that the 
majority of the cases of this kind recorded as having occurred to 
previous inquirers, were really instances of disease advancing from 
the tympanic cavity or mastoid cells outwards, to the meatus, in 
which process the cerebellum and lateral sinus were implicated. 

Treatment. — I have already stated it to be my opinion, founded 




THE EXTERNAL MEATUS 



107 



on a eoDsideration of eome of tbe cases alreadjr addnced, that when 
a disease of the brain originates in a, chronic affection of the car, 
the cause of its prolongation to the brain may be traced to the want 
of a free egtess for the matter. 

The modes in which this mutter may be confined arc various. In 
the case of the external meatus, the tumefied walls, together with its 
peculiar valvular disposition as seen in infants, create n sufficient 
barrier to the free egress of the secretion. In the tympanic cavity, 
the matter is usually retained by the membrana tympani, which 
either wholly or partially prevents its escape ; sometimes, however, 
the hypertrophy of the mucous membrane is itself sufiicient to shut 
np the secretion in parts internal to it ; and occasionally even the 
thick accnmulated matter itself may prove a bar to the egress of 
that which is beyond it. In the case of the mastoid cells, it appears 
that the matter may be retained by the peculiar position of their 
horizontal portion, the floor of which is often below that of the 
orifice into the tympanum ; or it may occupy the vertical portion of 
the cells, which is quite below the part leading into the tympanum. 
The rules to be laid down in ilie treatment of chronic catarrh of the 
dermoid meatus, the mucous membrane of the tympanum, and the 
mastoid cells, are as follow : — 

1. By attention to the general health to attempt to diminish the 
catarrh. 

2. To secure, if possible, a free exit for the secreted matter. 

3. By keeping up an external discharge, to cause that within the 
ear to he absorbed ; and thus to arrest further secretion, and allay 
the diseased action. 

General Treatment. — As far as general measures go, the same 
observations will apply to the diseases of each of the different parts 
of the ear. As it seems probable that the usual predisposing cause 
of these diseases is a scrofulous diathesis, every means should be 
taken to invigorate the health. Abundant exercise in the open air, 
especially in the country or by the sea-side, simple, nutritious, but 
not stimulating diet, and mild tonic medicine, are to be specially 
recommended. Great care should be taken that the patient sleeps 
in a well-ventilated room, in a bed without curtains, the head being 
kept high and cool, and above the bed-clothes. Everything which 
is liable to excite must be sedulously avoided ; and rough play, in 
which the head is apt to receive a blow, must not be allowed. From 
whatever source the discharge comes, it is desirable, v 



108 



THE EAR. 



cable, that the membrane whence it iseueH should be washed 
quently with tepid water; hence the use of the syringe is of great 
importance.' When there is congestion, the application of orit 
two leeches is desirable, and sometimes gentle couater-trritation 
should be resorted to. This may be effected by a liniment to bo 
rubbed over or around the ears and down the spine. Gentle astrii 
gents may also be used. Whatever may be the source of the dis* 
charge, as a general rule, its continuance for some months after the 
exciting cause is eymptomatic of a scrofulous or otherwise unhealthy 
diathesis ; and, in spite of every effort, the bypertrophied membrane 
ifi but very slowly affected, and consequently the discharge is gene- 
rally of long duration. It is important, however, that the medical 
man, knowing the exact nature of the disease, and its peculiarly 
chronic character, should inform the parents or friends of the patient 
that any attempt to stop the discharge by powerful astringenta, or 
otherwise than by gentle means, may be attended with serious con.? 
sequences, as the production of acute inflammation. Here, perhaps, 
I may be excused a few words on a subject so frequently adverted 
to as the danger of stopping a discharge from the ear. The sup- 
posed danger of an arrest of the discharge by local applications 
seems to have originated in the knowledge of the fact, that one of 
the most common symptoms in the early stages of acute inflamms^ 
tion of the ear, following upon a chronic disease, is the cessation of 
the discharge which previously, and often for many years, had been 
constant. There can be no doubt that in these cases the cossation 
of the discharge is one of the effects, and not one of the causes of 
the inflammation ; for other symptoms of inflammatory action may 
usually be observed before the discharge disappears. In cases 
where strong astringents have been employed in order to arrest a 
discharge from the ear, the symptoms that follow are not dependent 
upon the cessation of the discharge (for, indeed, the discharge doei 
not always diminish), but upon the inflammation caused by the irri- 
tant. 

To sum up what has been said respecting the general treatment, 



' Mko; or the flyringea 



;o Ihe . 



t fun 



cfnur 



inlcHniiBd indi* rubber 



neUl Douia sbonld b« m&ae eo ai to ft 
Ld be aUsd, Ibe naiile should be uken 
J) the bottle , or it maj be allowed I 
ig the ildu togslber. 




C, le the; do not send tb« wkter 
The bntund most simple for 
•ottlF, made b; Bell & Co. Tha 
remoTpd. When the sjringe ia 
lo be idjoclod should be pound I 
laving been pretioosly eipeUsd [ 




TRB EXTEBWAL MEATUS, 



109 



where there is simple chronic catarrh from the dermoid meatus, mem- 
, brana tympani, or the tympanic mucous membrane, with free egress 

for the matter : when there are symptoms of congestion, apply one 
I or two leeches near the part affected ; syringe the ear frequently 

with an abundant supply of warm water; use mild astringent lotions, 
1 and endeavor to improve the health by every means possible to the 
\ patient. In face of all these measures, the medical man may espcct 
[ to see the disease make very slow progress towards amelioration ; 

but he must be content that its advance inwards towards the bone 

and the brain is avertetl. 

In eases of catarrh of the dermoid meatus there is very frequently 

some source of irritation of the tympanic raucous membrane, of 
I which the catarrh of the meatus is but a symptom. Thus it is not 
■ uncommon to find obstruction of the Eustachian tube, even at the 
' faucial orifice, attended by catarrhal inflammation, and even by 

polypus in the meatus; both of which secondary affections wholly 

disappear when the primary disease ia removed. Cases of simple 

catarrh of the dermoid meatus do, however, occasionally occur: and 

one vrhich terminated fatally has already been cited. As a general 
r rule they may be distinguished from the secondary citses by the 
I absence of all appearance of disease in the tympanic cavity ; by the 
L power of hearing being but slightly affected, and by the healthy 
Relate of the membrana tympani, except an occasional increased 
t vascularity of its dermoid layer. Prinaary catarrh from the dermoid 

layer usually occurs in children suffering from debility; when the 
I dermis, instead of secreting its epidermis, pours forth a watery fluid 
t composed of serum, in which float epidermoid cells in different stages 
[ of development. This discharge has often an extremely offensive 
) odor, dependent generally, not upon the presence of dead bone, 
t "bM upon a deranged action of the ceruminous glands. The discharge 
f from the meatus, in cases of chronic catarrh, differs from that which 
L attends the same affection in the tympanum in the way already 
[ pointed out ; and it usually subsides under the use of a syringe and 
I tepid water, tonic medicine, and the ordinary plans for strengthening 
I the constitution of the patient. When the health is much deranged, 
F it may take some months to effect a cure ; but during tlie whole of 
I' this period daily syringing must be practised, 
(d.) Ulceration of the dermoid meatus. 
Cases of catarrh of the dermoid meatus, if neglected, may advance 
I to ulceration ; the bone may become diseased, and a small ( 



110 THE DISEASES OF T»E EAR. 

lamina may eventually be discharged; but ulceration of the soft 
meatus usually arises from the pressure of dead bone from the mas- 
toid cells making its way through the orifice of the meatus. 

Besides the ulceration of the dermis, alluded to above, as resulting 
from disease of the bono, a second kind of ulceration, viz., having a 
syphilitic character, is also met with. Its local treatment does not 
diflFer from that pursued in other ulcerations of the dermoid structure. 



CHAPTER VI. 

THE EXTERNAL MEATUS {continued). 



(t>L IPCS — 8T BU C T 



!MT — CASES, 3. 



Polypi. — Polypoid growths are not unfrequeutlj met with in the 
meatus, and, as already stated, are generally the result of long-con- 
tinued irritation of ita dermoid layer; aometimeB, however, they 
arise from chronic inflammation of the mucous membrane of the 
tympanum, or from obstruction of the Eustachian tuhc. As a, rule, 
polypi are attached to the surface of the dermoid layer of the meatus, 
although I have met with cases in which they sprang from the outer 
surface of the membrana tj-mpani, and in one dissection I found 
what appeared to bo a polypus growing from the inner surface of 
the latter. The existence of a polypus is always attended with a 
discharge of matter ; arising usually from two sources, — the dermoid 
layer of the meatus, and the surface of the polypus itself. In a 
cases there is a flow of blood, and generally u very offensive odor. 
A polypus, when small, usually causes little inconvenience, nor is 
its presence commonly detected, except by careful inspection ; — when 
it grows large, however, a sensation of fulness is felt in the ear, and 
not unfrequently there is a sense of heaviness, giddiness, and con- 
fusion in the head. These latter symptoms are greatly increased 
when the polypus projects beyond the meatus, and happens to he 
pressed upon. Such pressure I have known to produce complete 
insensibility. Sometimes there is also a shooting pain extending 
from the ear to the temple. These symptoms of cerebral irritation 



112 THE DISEASES OF THE EAR. 

frequently cause great alarm to the patient and his friends, and appear 
to be the result of pressure of the polypus on the outer surface of the 
membrana tympani, and chain of ossicles, which causes a movement 
inwards, towards the cavity of the vestibxde, of the inner extremity 
of the chain, producing continuous tension of the fluid of the vesti- 
bxde. This is clearly shown by careful inspection of a specimen 
prepared by me for the purpose, by which it is manifest, that although 
there are two articulations between the long process of the malleus 
and the base of the stapes, yet the slightest movement inwards of 
the processus longus mallei causes the base of the stapes to be 
pressed inwards towards the cavity of the vestibule : and, as has 
been already stated, pressure on the contents of the vestibxde 
appears to produce results very similar to those of pressure on the 
brain. According to my own observation, the former gives rise to — 
first, a sensation of noises ; secondly, confusion of ideas ; thirdly, 
giddiness and insensibility. 

In all cases of discharge from the meatus, the first step is by the 
syringe to cleanse the tube. This done, there is no difficxilty in 
determining whether a polypus be present, even though it should be 
situated close to the membrana tympani. 

Polypi of the external meatus may be divided into three classes. 

1. The one of most frequent occurrence, and which may be called 
the raspberry cellular polypus. 

2. That which has been termed the fibro-gelatinous polypus. 

3. The globular cellular polypus. 

Each of these classes, and its treatment, will now be separately 
described. 

1. The Raspberry Cellular Polypus. 

I have given this name to the polypus most frequently met with, 
which consists of nxunerous roxuid beads, very similar in appearance 

Fio. 27. 




Raspberry Cellalar Polypus. 

to the free surface of the raspberry. These beads are attached by 
small filaments to a central stem, which forms the root. Frequently 



THE EXTERNAL MEATUS, 



it is covereil by ciliated cpitbelium, and when exaniineJ micro- 
scopically, it3 interior is fouml to bo composeii of small roundoii 




u ttmcUiTe of lbs Baapb«rrj I'olypns, 



cells. So soft is it usually, ihat upon being seized by the ordinary 
dressing forceps, it breaks up, and bleeds freely. This kind of 
polypus varies much in size ; being somotimea not larger than a 
grain or two of mustard-seed, and at othurs so large its to fill the 
whole of the meatus, and project from the orifice. It is attached to 
various parts of the meatus, but generally to the inner half of the 
tube, and frei^ucntly close to the membraua tympani. When small, 
its color is usually deep rod ; but aa it grows, it becomes paler, and 
the rounded masses considerably increase iu size. The formation 
of these polypi is often attended with considerable pain, and by a 




A large Bupberry Polfpui, riiiblo at tha crifiGB ot tha HdrIiu. 



discharge of blood ; but it is not uncommon for them to remain un- 
disturbed for several years, during the whole of the time throwing 
off a most offensive secretion, and yet not producing symptoms suffi- 



114 



THE DISEASES OF THE EAR, 



ciently urgent to induce the patient to apply for relief; wliHe m'l 
other cases, again, the bead- symptoms are so distressing as to cause I 
serious alarm. 

The treatme7U usually adopted consists either in applying astrin- 
gent lotions and drops, or in CTideavoring to remove the mass by in- 
atramental means. As to astringent applications, there can be no 
doubt that tbey are usually ineffectual in preventing the growth of j 
tbe polypus, in diminishing its vascularity, or in abating the quan- 
tity of secretion. The same remark applies to the use of nitrate of ] 
silver ; for even under the influence of a strong solution of this sub- I 
stance, or of the solid nitrate of silver itself, I have seen the cellular \ 
polypus not only retain its vascularity, but rapidly increase Jn sise. 
The two plans adopted by me for the removal of this kind of poly- 
pus, are the application of the potassa cum calce, and tbe use of the 
lever-ring forceps. 

1st. Of the use of the potassa cum calce, — In the early part of 1 
1852, a series of papers were published by me in tbe Medical IHmet 1 
and Gazette, advocating the use of the potaasa cum calce ; but since | 
then I have suggested tbe use of the lever-ring forceps, the employ- 
ment of which is bo satisfactory that now I seldom resort to the 
former method. As, however, few medical men are likely to pos- 
sess that instrument, and as the use of the potassa cum calce ap- 
pears to be the ne.xt best plan for the removal of this excrescence, 
it is as well to give the result of my experience in that respect. In 1 
the first place, it is of consequence that the substance used should ] 
be made into very thin sticks. Those supplied to me by Mr. Squi 
in the form recommended by I>r. H. Bennet, answer the purpose 
extremely well so long as tbey retain their size and form ; 
this substance deliquesces very rapidly, the greatest care should be I 
taken to exclude it from the air. For use at St. Mary's Hospital, 
the potassa cum calce has been manufactured by Bailey, of Wolver- 
hampton, and recast into smaller sticks by Hopkins k Williams, of | 
New Cavendish Street. This material contains a small quantity of | 
iron, which makes its firmer and less deliquescent than that made ii 
the usual way. The latter preparation, as not requiring ao much j 
care, may perhaps suit those better who are not often required to 
apply tbe remedy ; though that which is free from iron is decidedly I 
the most efficacious. 

In applying the potassa cum calce, the first step is to syringe out I 
the ear with warm water, and the next to dry it with cotton-wo^. , 




THE EXTBBNAL MEATUS. 115 

TLe patient should then be placed before a strong light, so that the 
surgeon, having a distinct view of the polypus, may take a stick of 
the caustic in the right liand. while he holds the ear back with the 
left ; but the greatest care must be taken not to touch the surface 
of the meatus, which i» so extremely Beositive that the pain produced 
by the action of an escharotic upon it is most acute. For the pur- 
pose of shielding the meatus, an oval glass tube may be used; it is 
to be passed down the meatus as far as the polypus, when, by 
gentle pressure, a portion of the excrescence may be made to enter 
the distal end of the tube. The polypus, unlike the meatus, has but 
little sensibility, and the potossa is to be pressed gently against it, 
the immediate effect of which is to decompose the whole of the sub- 
stance to which it extends. If a pair of rectangular forceps be era- 
ployed, neither the hand of the surgeon, nor the instrument he em- 
ploys, will prevent the operator from seeing the polypus while he is 
making the application, and he can he sure that he touches the whole 
of the free surface. If this operation be carefully effected, the 
patient scarcely complains of pain ; but if any portion of the escha- 
rotic happens to reach the surface of the tube, the acute pain it 
causes can be immediately arrested by syriuging the ear with warm 
water, which should always be at hand. Supposing the potassa to 
have been thoroughly applied, the color of the polypus at once 
changes from a bright red to a lii'id hue. After the operation, the 
patient should sit still for three or four minutes ; and if the glass 
tube has been employed, it should be allowed to remain fixed as 
during the operation. Upon inspecting the polypus after three or 
four minutes, it will be found to he broken up, and blood to be ooz- 
ing from it ; while instead of its former rounded head, it presents 
an uneven pulpy mass. The meatus should next be syringed out 
with tepid water, when blood mixed with the debris of the polypus 
in a filamentous form comes away. The surface of the polypus still 
retains its dark color, and, during several hours, a process of slow 
dissolution lakes place in ail that part which the escharotic has 
reached. If the cotton-wool has rendered the polypus quite dry, it 
is desirable to moisten the potass* very slightly. As a general 
rule, the potassa may he again applied the following day ; and the 
process, already described, repeated, until the whole mass is de- 
stroyed. 

Cate I. Vascular polypi near the membrana timpani; singing m 
Ae ear; power of hearing diminishedf treated with potatsa cum 



116 



THE DISEASKS OP THE EAR. 



ealee; cure. — Mr. W. L., aged 40, was sent to me on the 20th Jnly, 
1850, by Mr. Cock, of Guy's Hoapitnl. He was a large, strong 
man, and in good health. He stated that five or six months ago he 
found that he was dull of hearing in the left ear ; this dulnesB waa 
removed hy the use of the syringe, which brought away a large 
qnantity of cerumen. Ho remained without cause of complaint 
until three months ago, when the symptom returned in the left ear. 
He was again in some measure relieved by syringing ; but this ope- 
ration was followed by a discharge of very offensive character, at- 
tended by a sensation of singing in the ear. He has at times com- 
plained of slight pain in the ear. On examination, the meatus vas 
found to be full of matter, which, after being removed, was seen to 
consist of adhesive mucus mixed with epidermoid cells ; the latter 
giving a milky aspect to the matter. The former presented nnme- 
rous small flocculi, or rather little particles like cotton thread, from 
aline and a half to three lines in length. On re-examination of the 
meatus, after this mucous fluid had been withdrawn, a red-colored 
polypus was seen, situated deep in the meatus, of which it apparently 
occupied the inner fourth, entirely obstructing the view of the mem- 
brana tympani. The power of hearing was much diminished, a watch 
not being heard except when pressed upon the outer ear. From 
the treatment of similar cases, I thought it undesirable to attempt a 
removal of this mass by instruments, not only on account of the soft 
nature of the polypus and its extreme sensitiveness, but also from the 
uncertainty as to the part to which the roots of the polypus were 
attached ; I felt also that if it were fixed to the raembrana tympam, 
the use of any force might be injurious to that organ. Having since 
ascertained by dissections' that the dermoid layer of the meatus is 
continuous with the dermoid lamina of the membrana tympani, it 
appears desirable on this account also not to use any force to a 
polypus attached to the vicinity of the membrana tympani, since a 
laceration of the meatus is likely to extend to the membrane. 

July 2l8t. — The potassa cum calce waa applied to the surface of 
the polypus in the way previously described ; and in the course of 
a minute the whole of that part of the polypus wliich could be seen 
became of a livid hue, and, when the ear was syringed with tepid 
water five minutes afterwards, numerous small particles of the poly- 
pus, softened and disintegrated, were brought away. The patient 




THE EXTERN 

complained of but very slight pain, wMch entirely disappeared on 
using the syringe. 

29th. — The polypus is smaller and less red ; the discharge from 
the meatus very copious. The potassa cum calce was again applied 
with similar results. 

August 13lh. — The polypus is observed to be much smaller, In- 
stead of the mass which, at the first examination, had an appearance 
like a raspberry, there was now only a rounded button, about a tine 
and a half in diameter. The potassa cum calce repeated. 

Oct. 18th, — The discharge is much diminished ; its odor is less 
fetid ; polypus nearly gone ; and the power of hearing much im- 
proved. 

Nov. 13th. — Since the last visit, a lotion, composed of a drachm 
of tannin to eight ounces of water, has been used twice daily. The 
discharge has now nearly disappeared, and consists almost entirely 
of epidermoid cells. The only vestige of the polypus conaiata in the 
presence of two very small buttons, each tho siae of a small pin's 
head ; these are attached to the upper part of the membranous mea- 
tus, close to the membrana tympani. 

2dth. — The use of the injection has been continued ; there is now 
BO vestige of the polypus ; the singing noise has ceased ; but the 
surface of the membrana tympani is dull. Hearing distance of the 
watch, six inches. 

The features of interest in this case appear to be : first, that al- 
though the escharotic was only applied at intervals of several weeks, 
the polypus did not increase in those intervals, but, on the contrary, 
gradually diminished ; secondly, with the destruction of the polypus 
the singing also entirely disappeared; thirdly, the return of the 
power of bearing to so great an extent. 

Case II, Discharge from the Irft ear during many years ; giddi- 
ne»» ; polt/pus ; treated by potasga cum calce ; cure. — The Rev. H. 
C, aged 40, consulted me on the 21st April, 1851. Ilia constitu- 
tion was not robust, as he had spent some time in India, The his- 
tory of his case is, that the left ear has been deaf from childhood ; 
that since early life he has been troubled with a discharge of offen- 
sive matter from that ear; and that lately be has complained of 
attacks of giddiness, especially upon suddenly rising from his chair. 
ypoti examination, a red polypus was observed to fill the inner half 
of the meatus. The same treatment was adopted in this case as in 
the last, with the exception that, as the patient lived in the country, 



118 



THE DISEASES OP THE EA 



he had the potassa cum calce applied two or three times in the spaee 
of nine or ten <Uvb, and then a larger interval elapsed before it 
was again usetl. The same result, however, ensued ; and at the 
end of six months the polypus had disappeared, and the eymptoma 
of giddiness wholly vanished. 

In another case, that of a patient aged 26, where the polypus filled 
the whole of the meatus, portions were^ removed by forceps and the 
remainder destroyed by potasaa cum calce. The symptom of spe- 
cial interest in this case was the production of giddiness hy pressure 
on the outer part of the polypus. 

In cases of polypus which coexist with catarrhal inflammation of 
the dermoid meatus, it is desirable to keep a slight counter-irritation, 
hy vesicating paper, over the mastoid process, while the polypus is 
being treated by the potassa cum calce. In order to remove the 
unpleasant odor of the discharge, an injection, composed of one part 
of the solution of chloride of lime to twelve parts of water, may be 
used three or four times daily. 

2d. On the removal of the vascular poljfjma by the lever-ring forrept. 
— Every surgeon who has attempted to remove a polypus, cspoeially 
when situated near to the membrana tympaui, must have found him- 
self unsuccessful, if he has used the ordinary forceps. In the first 
place, it is almost impossible to lay hold of the growth, on account of 
the small size of the tube preventing him from separating the blades 
of the instrument ; and should a large meatus enable him to do this, 
the instrument blocks up so much of the tube that he cannot see 
whether he lays hold of the polypus or not. Should the surgeon 
even succeed in seizing the polypus, he will find that it breaks up 
and the roots are not touched. 

Various instruments have been invented, having for their object 
the removal of the small vascular polypi from the external auditory 
meatus. Of these, one of the best is the snare of Mr. Wilde, thus 
described at page 420 of that gentleman's work on "Aura! Sur- 
gery:"— 

" It coDBists of a fine steel stem, five inches long, and bent in the 
centre, with a movable bar sliding on the square portion near the 
handle, which latter fits over the thumb. The upper extremity is 
perforated with holes running parallel with the atom, and loops at 
the angle serve the same purpose. A fine wire, fastened to the 
cross-bar, passes through these loops and holes; it should be of such 
length, that when the cross-bar is drawn up tight to the handle, the 




EXTERNAL MEATUS. 



ligature ia fully on the stretch. ... In using it, the cross-bar ta 
pushed forward, and n. noose made of the wire at the small extre- 




mity, of sufficient size to include the morbid growth, which it is then 
made to surround, and towards the roots of which it is pressed by 
means of the stem ; the cross-bar is then drawn up smartly to the 
handle, while the point of the stem is pressed downwards; and it 
never fails of either cutting across, or of drawing with it whaterer 
was included in the nooae." 

The difficulty attendant upon the use of this instrument, consists 
in getting the wire noose around the polypus, which frequently is of 
very small size ; another disadvantage is, that it cuts off a portion 
of the growth, instead of withdrawing it entire. 

The instrument which I have been in the habit of using during 
several years at St. Mary's Hospital, as well as in private practice, 
with most satisfactory results, I have called the lever-ring forceps. 
In the interior of a tube is a delicate steel rod, the end of which ia 
split into two portions, each having a small oval ring at its extre- 
mity, measuring four or five lines long, and from two to three broad. 
These rings {the inner surfaces of which are slightly serrated) are 
separated from each other when the lever ia not pressed ; but as soon 
ae it is pressed, the rings are brought into contact. The instrument 




m^J^^B 



The LoTBr-riog Forcujia, o[ien. 

is introduced into the meatus with the rings apart, which having 
been made to inclose the polypus, or a portion of it, between them, 
the lever is pressed down, the polypus seized, and instantly drawn 



120 THE DISEASES OF THE EAR. 

(7(Me III. A cellular raspberry polypus in each ear removed by the 
lever-ring forceps; great improvement. — M. I., aged 20, in good 
health, but having a tendency to glandular enlargements, consulted 
me on March 7th, 1853. 

History. — ^Whcn a child, suffered on several occasions from attacks 
of deafness, which lasted from ten days to three or four months, but 
by degrees disappeared. Between three and four years ago, the 
left ear began to discharge, and has continued to do so up to the 
present time. Within the last two months, the power of hearing in 
the left ear has so much decreased that he requires to be loudly 
spoken to close to it. A month ago, the right ear began to discharge, 
and is nearly as deaf as the left. 

On examination^ the watch was heard by the left ear when pressed 
against it ; by the right when in contact. In each ear, near to the 
membrana tympani, was a large vascular polypus. When an attempt 
at a forcible expiration was made with closed nostrils, air passed 
freely out of the left meatus, but not through the right. The mucous 
membrane of the fauces was thick and red. 

Previous treatment. — Excision of the tonsils, and the introduction 
of cotton-wool into the bottom of the meatus. Neither operation was 
productive of benefit. 

Treatment. — The polypus, by means of the lever-ring forceps, was 
first removed from the right ear. The patient stood upright, and 
reclined the head slightly towards the left shoulder. The gas lamp 
being held between the teeth, the patient's ear was drawn backwards 
by the left hand, so as to dilate and straighten the meatus as much 
as possible ; a large-sized speculum was next introduced ; and then, 
with the right hand, the lever-ring forceps was gradually pushed 
down to the polypus with the rings in contact. As soon as the rings 
reached the polypus they were allowed to separate, and when thus 
apart were made to surround the growth ; when this was effected, 
the rings were brought into contact by pressing on the lever. The 
instrument was then withdrawn, bringing with it the polypus, and 
leaving the membrana tympani exposed. During the whole of the 
operation I was able to see what I was doing, the rod of the instru- 
ment being so small as to occupy only a trifling portion of the tube. 
On the following day the hearing of the patient was much improved, 
the watch being heard at a distance of two inches ; and the quantity 
of discharge had greatly diminished. The polypus in the left meatus 
was now attacked ; but as only small portions of it came away at a 



THE EXTERITAL URATFS. 131 

timo, three or four operations wore reqnired, which were followed by 
much itiiprovemcnt. A large aperture "was detected in the metnhrana 




^mpani, and, hj the aid of the artificial membrane, the hearing 
power was still further improved. 

Caae TV. Obstruction of the Eustachi-m tuhe at thefauaial orifice; 
eeUular polyput in the external meatus ; removftl ; cure. — H. W., 
Esq., aged 19, pupil to an architect, consulted me on February 
19th, 1854, on account of deafness in both cars, and discharge from 
ihe right. 

HiBtory. — From childhood has been subject to attacks of deafneae 
daring a cold ; but they have disappeared after a duration of three 
or four weeks. About two years ago, he had an attack of deafness, 
which was followed by discharge from the right ear ; this has lately 
increased, while the hearing power has considerably diminished. At 
the present time he has to be spoken to in a loud voice within the 
distance of a yard. On examtnatiuri, the watch was heard only 
when in contact with the right ear. There was a large quantity of 
muoous discharge in the meatus, on removing which, a red polypus, 
with numerous projections from its surface, was seen to occupy the 
inner half of the tube. The Eustachian tube was impervious. Left 
tar — hearing distance six inches ; memhrana tympani opaque and 
partly calcareous ; the Eustachian tube impervious ; and the mucous 
membrane of the fauces red and thick. 

Treatment. — On the 25th February, by means of the lever-ring 
forceps, I removed a polypus as large as a horse-bean, which was 
attached to the posterior surface of tiie meatus, close to the mem- 
brana tympani. On the Ist March, the discharge had nearly 



122 THE DISEASES OF THE EAB. 

ranished ; and the membrana tjinpani was seen to be entire, tbongh 
calcareous at parts, ^he hearing was much improved ; the watch 
being heard at the distance of two inches. Tonic medicines were 
administered ; the surface of the body to be sponged with vinegar 
and water : and an acid astringent gargle to be used thrice daily. 

March 8th. Hears much better. Two days before, after garg- 
ling« a sudden crack was felt in the right ear, after which he heard 
most acutely. Does not hear quite so well to-day, but still hears 
general conversation. 

April 3d. — The left ear has also much improved : can now hear 
perfectly. 

March, 1855. — Have seen this patient recently, and he has re- 
mained quite well. 

CiUeY. Cellular polypu9. causing deafness and serious cerebral 
symptoms; removal; cure. — I. E., Esq., aged 21, was sent tome 
by Dr. Conolly on the 10th February, 1855, on account of deafness 
in the left ear, accompanied by occasional giddiness. 

History. — Since six years of age has been subject to an offensive 
discharge from the left ear, with an occasional flow of blood : has 
not experienced pain, but has frequently had a sensation of fulness 
in the ear : and when the ear has been pressed upon, there has been 
considerable giddiness. Recently, symptoms of unnatural mental 
excitement have been experienced. On examination^ it was found 
that the watch could not be heard, though the crack of the nails 
was distinguishable. On looking into the ear, a polypus was seen 
within half an inch of the orifice of the meatus, deep red in color, 
and covereil by a transparent discharge. Pressure at once produced 
a sensation of giddiness. 

Treatment, — The polypus being of a large size, and somewhat 
firm, it was resolved to attempt its removal by the ring forceps ; a 
considerable portion of the mass was thus extracted but the roots 
remained. Great relief at once followed the operation ; and ulti- 
mately the lever-ring forceps succeeded in removing the rest of the 
morbid growth. The membrana tympani was found to be entire ; 
the hearing was greatly improveil, and the head-symptoms wholly 
disappeared. 



EXTERNAL MEATUS. 



2. The Fibro-Ge latino rs Polypus. 

Next in frequency of occurrence to the vaacular is the one termed 
the gelatinous polypus. This name has been given to it from the 
Boft jelly-like appearance of its free portions, and from the similarity 
of its general aspect to the gelatinous nasal polypus. Careful and 
minute examination, aided by the microscope, does not, however, 
confirm the propriety of the designation, for, as will bo seen pre- 
sently, the term ^'fihi-o-gelatinous polypus" would be the more ap- 
propriate appellation. 

Structure of gelatinous polypus. — This morbid growth generally 
attains to a large size. There are in my museum specimens vary- 
ing from the size of the la-st joint of the thumb to that of a small 
bean. Sometimes this polypus has a single root and body, but more 
usually two or more bodies have a common base. The root, which 
is attached to the wall of the meatus, is generally not larger than a 
line or two lines in diameter. Examining the polj-pus as it ap- 
proaches the orifice of the meatus, near the root will be found at- 
tached numerous small rounded growths very like delicate granula- 
tions, which appear to be the rudimentary growths prevented from 
developing by the pressure exerted upon them by the walls of the 
meatus and the larger expanded part of the outer portions of the 




growth. Approaching the orifice of the meatus the polypus assumes 
a globular form, consisting of from one to as many as six or eight 
rounded heads. When these heads are numerous, they have pedicles, 
varying in length from a quarter to half an inch, and connecting 
them with the root. The surface of this polypus is smooth, and is 
cooBtituted of a layer of about a quarter of a line thick, which may 



124 THE DISEASES OF THE EAR. 

be separated from it by maceration, and which consists of cells bear- 
ing every resemblance to those of the epithelium covering the buccal 
mucous membrane. This epithelial layer is as thick and white as 
ordinary writing-paper ; and when detached and floating about, it 
retains the shape of the polypus of which it had formed the surface. 
The interior of the gelatinous polypus is composed of corpuscles and 
fibrous tissue, varying in proportion in different specimens ; but the 
fibrous tissue generally predominates. The corpuscles have a rounded 
form, but vary in size and shape. In a specimen which was a fair 
example of this kind of polypus as it comes under the notice of the 
surgeon (it being white and soft, and readily compressible by the 
thumb and finger), I found these cells varied in shape from a perfect 
round to an irregular oval, — and in size, from that of a blood-cor- 
puscle to a half or one quarter of its dimensions, the greater number 
appearing certainly smaller than the blood-disc ; but they presented 
every variety of size between that disc and a fine granule ; and thtre 
was very little symmetry in form or size even between those which 
were nearest to each other. These cells are not generally in close 
contact, but are separated by a delicate gelatinous substance, which 
is sometimes quite transparent and structureless, and occasionally so 
abundant as to form by far the largest portion of the mass. In parts 
where the polypus is resisting, these cells are separated by delicate 
wavy bands, having the appearance of fibres ; and to the surface of 
these fibres the cells are observed to adhere. In some parts these 
wavy gelatinous-looking fibres form almost the entire substance of 
the polypus, the rounded cells being scattered very sparingly : in 
others these fibres are absent. The wavy fibres run in the long dia- 
meter of the polypus, possess considerable toughness, and although 

Fig. 34. 




Strnctare of the Fibro-gelatinou8 Polypus. 

easily separated from each other and isolated, they cannot be torn 
across without considerable force. In some instances these fibres 
are extremely firm, and the polypus is entirely composed of them. 



THE EXTERNAL MEATUS, 



125 



BO as to become solid and very bard. When separated from each 
other, they wear the appearance of transparent lines, whose diameter 
varies from half to a quarter of that of the blood-disc. Interapereed 
through the uubstance of the polypus were many spindle-shaped 
crystals. On the application of acetic acid, the fibres became 
swollen, and assumed a confused gelatinous appearance, losing all 
their fibrous character ; the corpuscles were also converted into a 
similar mass, in which, however, a large number of granules were 
observable. The action of the acetic acid also brought into view 
a large addition to the number of fine spindle-shaped crystals pre- 
viously seen. The gelatinous polypuB sometimes attains to so great 
a degree of hardness that it is with ditEculty cut through by a pair 
of scissora ; a condition which appears to be produced by the in- 
crease in quantity and solidity of the fibrous tissue, the diminution 
of the quantity of corpuscles, and the absence of the gelatinous 
matter between them. It has been already stated that the vascular 
polypus is composed of rounded cells ; which, however, differ very 
much from the cells of the gelatinous polypus, in being ail of nearly 
the some size and shape, and larger than those previously described. 
The cells of this polypus do not appear to be separated by any 
substance, but they are agglomerated together and form the entire 
mass of the polypus. Its exterior also is smoother than that of the 
gelatinous kind, ia always covered by its secretion, and is composed 
of a layer of epithelial cells which frequently terminate in ciliie, that 
often continue in active motion for a long time after the removal of 
the portion of polypus which they cover. 

Treatment of the gelatinous poli/pus. — The difference in the struc- 
ture of the three kinds of aural polypi, naturally prepares the sur- 
geon for a difference in their treatment. This ia undoubtedly neces- 
sary. The use of the potassa cum calce, which has proved so effica- 
cious ill the destruction of the vascular polypns, is of but little 
service in the treatment of the gelatinous, or, more properly speak- 
ing, the fibro-gelatinous polypus. The eacharotic produces so trifling 
an effect upon fibrous tissue, that removal by extraction must always 
be resortetl to. For this purpose, the best instrument is a pair of 
ring forceps, the enda of which should be reduced in size so as not 
to be larger than from two to three lines in diameter. These for- 
ceps should be introduced into the meatus to the distance of half or 
three-quarters of an inch, and the polypua seized as near as possible 
to its roots ; the forceps should then be used as a lever, the outer 



126 THE DISEASES OP TUE EAR. 

part of the ear being tlie fulcrum, und tlio polypus turned out o 
cavity. But little force is required ; aud, as a general rule, 
diseased growth is extracted -without difficulty in an entire ati 




Tho Eing Forceps. 

In one case, that of the wife of a medical man, a large gelatinota 
polypus, which filled the greater part of the meatus, was retnovei 
by the fret]uent use of the syringe and warm water. The tractim 
produced by the water in making its way outwards, seemed i 
first place to diminish the supply of blood to the growth, which gr** 
dually darkened in color, and was ultimately expelled. On exam- 
ining the meatus after the removal of the polypus, the surface to 
which it was attached is distinctly discernible, and, for a short time, 
there is a slight oozing of blood from it. In some cases, portiona 
of the root of the polypus remain ; they do not, however, generally 
require any further treatment, but gradually wither and disappear. 
If, on the other hand, any of the small globular bodies remain at> 
tached to the root, they rapidly increase, and the diseased growA 
has again to be submitted to operation. The removal of the fibro- 
gelatinous polypus is generally productive of relief, not only to thft 
unpleasant head-symptoms caused by its pressure on the contents of J 
the vestibule, but to the diminished power of hearing. The latter 
improvemeDt does not, us might be supposed, take place at onoe; 
on the contrary, it is not unusual for there to be at first no increase 
of hearing power, though it gradually and very slowly improves. 
This may, perhaps, be accounted for by the circumstance, that tb« 
polypus has for a long period exerted considerable pressure upOB 
the membrana tympani, or, where that structure no longer exist 
upon tho tympanic ossicles ; which organs only slowly return to thai 
natural state. 

C'ate VI. Gelatinous polyptt» in the left ear for teven yeatB — eft 
the right ear for one year ; noiae% in the right ear; giddiwai % 




presiure of (he pulypus. Care hy extraction, followed by the appli- 
cation of alum and chloride of zin^.-r-TIarriet Wenlock, aged 58, a 
wasberwoman, strong, rather stout, and in good health, with the ex- • 
ception of the Bytnptoms produced by the polypus, consulted me in 
the beginning of April. 1850, She stated that seven years pre- 
viously, without any other symptoms, a discharge issued from the 
left ear, which has never disappeared ; and shortly after the appear- 
ance of the discharge, a rounded body was visible at the orifice of 
the ear. About a year ago, the right ear also began to discharge, 
and there soon appeared a swelling at the outer orifice. She com- 
plains of great noises in the right ear ; these vary much : sometimes 
they appear like a humming, at others like the tinkling of a bell, — 
then as if it were loudly ringing. When the surface of the tumor 
in the left ear is pressed upon, she feels giddy, and if it is continued, 
loses her consciousness, and falls. At present, and for a long time, 
Bhe has been so hard of hearing, that she requires to be loudly ad- 
dressed close to the head. On examination of the right ear. a 
round, pale-colored polypus, more than half an inch in diameter, 
was seen protriiding from the orifice of the meatus, below which 
was another growth about half the size. At the external meatus of 
the left car a rounded body was observable, of not more than a line 
in diameter, and not extending beyond the orifice. Kot finding any 
symptoms which indicated an affection of the bone, I thought it best 
at once to remove the polypi, and selected the right ear to begin 
upon. The diseased growth was removed with the greatest ease by 
the use of the ring dressing forceps in the manner before described; 
the patient suffered only a slight and momentary pain, and there 
was a very trifiing oozing of blood. On examining it after removal, 
the polypus was found to consist of the two rounded heads already 
noticed, each having a second mass, about half the size, continuous 
with it, and extending nearly as far as the root, which was very 
narrow, not heing more than a line or a line and a half in diameter. 
The surface of the cxpiinded part of this polypus was found to be 
covered with flat scabs, like those of epidermis ; but nearer to the 
root, elongated cells, armed with ciliie, were also distinguishable. 
The rounded parts, which were exposed to the air, were smoother 
and whiter than those which were concealed ; the latter presenting 
a somewhat rugous surface. On April 2'2, a fortnight after, exa- 
mination showed the quantity of the discharge to be greater than 
nsual, and a rounded growth was perceived near to the membrana 



128 THE DISEASES OF THE EAB. 

tjmpani, as if the roots of the polypus still remained ; to this sub- 
stance a solution composed o£ half a drachm of alum to two ounces 
of water was directed to be applied thrice daily. The polypus was 
removed from the left ear, and found to consist of a pedicle, a body, 
and three rounded heads, two of which had been visible at the orifice 
of the meatus during life. . 

April 20. — The power of hearing is improved. Has had slight 
pain in each ear, also some giddiness. The discharge, though less 
abundant, is still of an offensive odor. In the right ear the rem- 
nant of the polypus is seen attached to the upper part of the meatus 
near to the membrana tympani : in the posterior part of the latter 
an orifice was observed. In the left ear the roots of the polypus 
appeared to fill as much aa one-half of the meatus. The drops of 
the solution of alum to be continued. 

May 6. — Right ear. — The discharge has ceased, the hearing has 
improved, and is much better after blowing the nose. The polypus 
has entirely disappeared, and the mucous membrane of the tym- 
panum, which is thick and red, is seen through the orifice of the 
membrana tympani. 

Left ear, — The roots of the polypus are much in the same state. 

May 13. — The roots of the polypus remain as a week ago. Ap- 
plied the chloride of zinc to their surface. 

May 27. — Polypus of left ear smaller ; again applied chloride of 
zinc. 

June 24. — Discharge from left ear gone. The polypus much di- 
minished in size. Air passes through the left membrana tympani. 
The solution of alum was continued, and in a fortnight the polypus 
had wholly vanished. 

Case VII. Gelatinous polypus cured hy extraction ; hearing potver 
improved, — J. W., Esq., aged 24, a medical student, pale and not 
strong, consulted me on the 24tli October, 1851, on account of so 
great a degree of hardness of hearing, that he was obliged to be 
spoken to at a distance not further than a foot from his head. He 
had also an abundant discharge from the left ear. The history of 
the case was, that twelve years ago he had an attack of porrigo, for 
which the head was shaved. During this attack he was very deaf 
in both ears, but quite recovered. A year ago, he became slowly 
dull of hearing in the right ear ; and for eight months the left ear 
has been gradually losing its power of hearing. Has had pain in 
the left ear lately, with a discharge, which varies much in quantity, 



THE ESTEttNAL MEATUS 



and has a very offensive odor. On examination, tlie hearing power 
of the right ear, tested by the wiitcli, was only half an inch; the 
surface of the menibrana tynipani, was dull, and its substance 



L^t ear. — Watch only heard when pressed upon the ear. A 
polypus filled the meatus and extended as far as the outer orifice : 
it was removed by the forceps, and the power of hearing slowly 
improved. 

Caae Vllf. Gelatinous polypus removed by forceps, and potaita 
cum calce applied to the roots; cure. — Miss E. H., aged 26, con- 
sulted rae on April 4, 1851, on account of a discharge from the 
right ear. The history of the case, as detailed to me, was, that aft- 
the age of sixteen, she had an attack of scarlet fever, with pain in 
both ears, especially in the right. The pain in the right ear was 
followed by a discharge, which has continued to the present time, 
with the exception of its once disappearing for a fortnight, when 
the pain greatly increased. On examination, a leaden-hued polypus 
was seen projecting from the orifice of the meatus, which was stated 
to have been seen there during the four months preceding the appli- 
cation for advice : pressure upon it had always produced giddiness. 
This polypus was found to bo attached to the posterior and inferior 
part of the meatus, close to the membrana tympani. It was removed 
by the dressing forceps; and as the roots had a tendency to increase 
in size, the potassa cum calce was applied once, and the growth was 
effectually destroyed. 

Case IX. Gelatinous polypus following bathing; removed by ope- 
ration; cure. — J. D., Esq., aged 36, consulted me on May 20, 
1853, on account of deafness in the right ear, with discharge. 
History. — Five years ago, after bathing in the sea, had pain in the 
left ear, followed by a discharge, that has continued ever since, and 
at times been very offensive. For the last two or three months this 
ear has become so deaf that he can scarcely hear at all with it. On 
examination, a large gelatinous polypus was found occupying the 
meatus nearly as far as the orifice. It waa taken out by the ring 
forceps, and the hearing was immediately improved. An orifice 
was detected in the posterior part of the membrana tympani. The 
patient's hearing continued to improve ; the watch was heard at a 
foot from the car ; and the discharge wholly disappeared. The 
roots of the polypus were found to have been attached to the sur- 
face of the meatus in the vicinity of the membrana tympani. 



ISO THE DISEASES OF THE EAB. 



3. The Globular Cellular Polypus. 

The third kind of polypus developed in the external meatus is the 
globular cellular species. I have thus named a growth which essen-' 
tially differs from those belonging to the preceding classes. It consists 
of a single globular mass, perfectly smooth on the surface, and with- 

Fig. 36. 



^^ 



GlobaUr CellnlAi Polypus. 

out any appearance of granulation. It is confined to the inner fourth 
or sixth of the meatus, from the upper part of which it is usually de- 
veloped, and it hangs down like a curtain, wholly or partially con- 
cealing the membrana tympani. It is of a deep red color, is softer 
than the ordinary cellular polypus, and does not generally attain 
a size larger than a small pea. This growth usually occurs in chil- 
dren or in young persons ; it is attended by a mucous discharge, 
which is often very offensive ; and the secretion, like that from other 
forms of polypus, consists of epidermoid cells, which give a milky 
appearance to tlie water after syringing : — it also contains fine 
threads of mucus. This kind of polypus may exist for several 
years without producing any severe symptoms ; and it has not 
hitherto been distinguished from the other varieties of polypus. It 
may be discriminated from the disease I have called chronic catar- 
rhal inflammation of the dermoid meatus, by the discharge contain- 
ing flocculi of mucus, like small particles of thread, and from its 
always presenting a red mass at the inner extremity of the meatus. 
This affection also differs from catarrhal inflammation of the meatus, 
in never terminating in disease of the bone ; the discharge appear- 
ing to proceeil from and be confined to the surface of the polypus 
only. The aural disease with which the globular cellular polypus 
is most likely to be confounded, is catarrhal inflammation of the 
muct>us membrane of the tympanum : since, in some cases of the 
latter, the mucous membrane is of a deep red color, and so much 
tumefies! that it projects into the meatus for a line or a line and a half 
beyond the position occupieil by the membrana tympani previous to 



THE EXTERNAL MEATUS 



131 



"SeBtmction. On examining the growth hy means of the specu- 
lum and lamp, it is not always easy to determine wliich of the two 
diseases just described is present. The examination of the dis- 
charge, however, is sufficient to decide the question ; for, although 
in both affections floccular mucus is present, that accompanying the . 
polypus is composed of small thread-like particles, while that emana- 
ting from the mucous membrane of the tympanum presents large 
irregular-shaped masses, generally of a yellow color. The history 
of the case wilt also usually aid the surgeon in forming a diagnosis, 
as the globular cellular polypus ordinarily appears without the mani- 
festation of any very decided symptom ; perhaps the appearance of 
the discharge is the fii-st indication of its existence : whereas the 
affection of the tympanum generally originates in an attack of acute 
inflammation, and often arises during scarlet fever or measles. 

Treatment. — The treatment of this kind of polypua is much more 
simple than that of the two species first described ; nevertbelesB, 
except the true nature of the disease be ascertained, it is useless to 
employ the astringent applications commonly prescribed to arrest 
discharges from the ears. This affection stands between the ordi- 
nary vascular polypus and catarrhal inflammation of the dermoid 
meatus ; the former being wholly uninfluenced by the use of the 
strongest astringents, and the latter being generally curable by 
weak solutions of them : whilo the globular cellular polypus, though 
affected by astringent applications, requires them to be of conside- 
rable strength. The course of treatment followed by me, consists 
in syringing out the meatus of the affected ear with tepid water, to 
remove all discharge ; and after the ear has been turned towards 
the shoulder of the side affected, to allow of the water running out, 
then to let throe or four drops of an astringent solution fall into the 
meatus, and close the ear for half an hour by a portion of cotton- 
wool, moistened with the solution. This course may be repeated 
twice, thrice, or oftener, during the day, care being taken that the 
sediment from the solution be removed before the drops are repeated. 
The preparations used by me are the acetate of lead, zinc, alum, or 
tannin ; but the firsl-named Las, I think, answered best. This 
species of polypus may often be removed in a week, or from that to 
a fortnight ; and, to prevent any congestion in the tympanic cavity, 
a slight discharge from the surface of the mastoid process has gene- 
rally been kept up during the employment of the astringent solu 
tion. 



132 



ES OF THE EAR. 



C««e X, Globular cellular jjoljfpm; diiscliargc for three yearg; 
cured hy the solution of liquor plumbi. — Mibb F. A., aged 12, of a 
rather weakly coiistitutiou, was brought to conault me on the 30th 
of March, 1850. Her mother stated that she had heen dull of hear- 
ing during several years, in the left ear ; and this dulnesB has of 
late so much increased, that when the right car is pressed upon the 
pillow, she cannot hear even loud voices. During the last three 
years there has been a discharge from the ear, which has sometimes 
been very offensive, and at times, especially in the morning, it has 
been of a dark color. There has been no complaint of pain in the 
ear ; but a tenderness below it has been felt. At times there has 
been pain over the left eyebrow, extending occasionally to that ade 
of the head. On examination, it was found that the watch was 
heard only in contact with the ear. By the aid of the speculum, a 
globular red growth, like a polypus, was discovered, concealing the 
membrana tympani, with the exception of a small semilunar shaped 
portion at its inferior margin (about half a line in diameter at its 
centre), which was quite opaque. As this growth did not extend far 
into the meatus,- — ^as it was of a deep red color, and its surface quite 
smooth, it presented an appearance very analogous to that of the 
thickened mucous membrane of the tympanum ; which, as has been 
stated, becomes sometimes so much bypertrophied, as to project into 
the meatus, and occupy a position nearer to the orifice than the 
membrana tympani did previous to its destruction. The presence 
of the latter membrane was in this case, however, ascertained ; by 
the use of the otoscope, air was heard to enter the tympanic cavity 
without passing into the meatus ; and the small portion of the mem- 
brana tympani which was visible, could be observed to be pressed 
out, and rendered tense and white, when the tympanic cavity was 
filled with air. It was clear, therefore, that the diseased growth 
was a polypus. 

The treatment pursued consisted in applying to the surface of the 
polypus, thrice daily, a solution of the diacetate of lead ; and, as I 
was not to have the opportunity of seeing the patient for two or 
I three months, it appeared desirable that the solution should not be 
Ego strong as would otherwise have been advisable, bo only six drops 
Fof liquor plumbi were added to an ounce of water. 

June 18th. — The discharge has nearly disappeared, and exaodna- 
tion shows the polypus to be reduced 4o the size of a large pin's 





EXTERNAL ME 



133 



orad. The hearing was improved, the watch being heard at two 
inches instead of only when in contact. 

I had no opportunity of seeing this patient again; but some little 
time after the last visit, I heard that the discharge had ceased, and 
the hearing so much improved that she was considered cured. 

Ca»e XI. Glohalnr polypus in right ear broken up by forceps, and 
a lolution of liquor phi mbi applied; cure. — Master A. II., aged 16, 
was first seen hy me on the 13th of April, 18.50. Both tonsils were 
enlarged ; he had a tendency to glandular enlargements ; and was 
at the time of his visit far from being in strong health. The history 
of the case was as follows : — At six years of age he had an attack 
of scarlet fever, which left him dull of hearing, a dulnesa that has 
increased during the last two years and a half; has had discharge 
of an offensive character from the right ear during the last eighteen 
months. 

Might ear. — On inspection, a polypus was observed at the inner 
extremity of the meatus, growing from its upper part, near to the 
membrana tympani. The polypus was red and globular, with a 
smooth shining surface. The discharge removed from the meatus 
was white like milk, not viscid ; and it consisted of rounded cells 
similar to those excreted in catarrhal inflammation of the mucous 
membrane of the tympanum, and the nuclei of which were rendered 
very distinct by the addition of acetic acid. By aid of the otoscope, 
air is heard to enter the tympanic cavity ; and in doing so, to pro- 
duce a loud sound, like that attendant upon the sudden distention of 
a bladder by air. The watch was not heard over the ear, but only 
when pressed upon the temple. 

Left ear. — The memhrana tympani was dull on its surface, and 
white. Air passed into the tympanic cavity, producing a sound 
similar to that in the right ear. Hearing distance, a quarter of an 
inch. 

April 17th. — By means of the rectangular forceps, the outer part 
of the polypus was broken up ; it was very sensitive, and bled 
slightly. A solution of diacetato of lead in water (four grains to the 
ounce) was ordered to be dropped into the ear thrice daily, and a 
cantharidine cerate was applied to the nape of the neck. 

25th. — The discharge much diminished, and its offensive odor has 
disappeared ; the polypus is only one-third its former size, and the 
membrana tympani is seen beyond its lower border. 



134 THE DISEASES OF THE EAR. 

May 4th. — Much the same ; prescribed a solution of chloride of 
zinc (ten grains to the ounce) to be dropped into the car. 

16th. — The discharge has disappeared; the hearing so greatly 
improved that the patient thinks he sometimes hears quite well ; 
the roots of the polypus alone remain. The treatment was con- 
tinued ; and when I last saw the patient, on the 13th September, 
he was quite well. 

In the following case, I adopted a more active plan of treatment. 
Being aware, from actual examination, that polypoid growths of the 
nature now under consideration are extremely soft, in order to re- 
move them more rapidly, I resolved to apply an astringent to them 
of much greater strength than those previously used ; and the com- 
plete success of this proceeding was very manifest. 

Ca%e XII. Globular cellular j^olypus destroyed by a strong soltir 
tion of acetate of zinc. — Miss T., aged 21, of fair complexion, and 
in good health, applied for advice on January 13th, 1852. The 
history of the affection is, that seventeen years ago, after an abscess 
behind the right car, its hearing power greatly diminished, and has 
never returned. Six months ago, a discharge issued from this ear, 
which has continued without intermission to the present period. On 
examination of the right ear, the watch could be heard only when 
in contact, and the meatus contained a considerable quantity of dis- 
charge, consisting of tenacious thready particles of mucus, and 
mucous cells. At the inner extremity of the tube, a globular- 
shaped polypus, of a red color, was discovered, attached to the 
upper part of the membranous meatus, close to the membrana tym- 
pani, which it wholly concealed, with the exception of a small semi- 
lunar shaped portion seen at its lower border. 

Left ear. — Hearing distance one inch. Membrana tympani white 
like cartilage. 

Treatment. — The right ear to be syringed out with tepid water 
thrice daily, and, after each operation, four minims of a solution of 
acetate of zinc (forty grains to the ounce) to be dropped into the 
ear. A small portion of vesicating paper to be kept over each mas- 
toid process. 

January loth. — Slight pain was felt for half an hour after three 
applications of the drops ; and yesterday the patient complained of 
a sensation as if the ears were distended. The discharge is di- 
minished in quantity. The polypus had a grayish hue, bled on 



THE EXTERNAL MEATUS. 185 

being touched, and appeared partially broken up. Large particles 
of the acetate of zinc had collected on the surface of the polypus. 

19th. — ^Polypus smaller ; no discharge ; has had a good deal of 
ear-ache. To syringe with warm water, and omit the use of the drops. 

22d. — The pain is gone ; there is no discharge ; the polypus has 
wholly disappeared. The membrana tympani is now seen ; its upper 
and posterior part is white and thick ; at its anterior part, there are 
two small apertures, through which the mucous membrane of the 
tympanum is seen to be red and thick ; the hearing has improved : 
the watch is now heard by the right ear at a distance of three 
inches ; by the left, at a distance of two inches. Subsequent re- 
ports from this patient state that the discharge has not returned, 
and that the hearing continues to improve. 



CHAPTER VII. 

THE EXTERNAL MEATUS [coadudtd). 

TUMORS. 



I. Osseous Tumors. 

However little it may have hitherto attracted the attention of 
the profession, there is reason to suppose that the growth of osseous 




Two Owfooi Tumors prtij«linf f mm lh» ■nl»rinr and [w^lcTiamlls of the HMiDiEilar- 
DOf, IcaTiu; ■ mull triuigulsr iprrlnre b«tDir. 

tumors in the extornnl meatus of the oar is a disease of no unfre- 
qucnt occurrence. Such tumors appear to be the result of a rheu- 



TEE EXTERNAL MEATUS. 



137 



matic or gouty diathesis, and may be developed in any portion of 
the length of the tube ; but the part from which they most com- 
monly originate ia about the middle third of the passage. In one 
case, however, the tumor extended beyond the outer orifice of the 
osseous meatus, and could be felt by placing the little finger at the 
meatus. Occasionally the posterior wall affords the point of origin 
to the tumor, and then it not unfrequently resembles a simple bulg- 
ing of the ^all. In other cases, a similar tumor is also developed 
from the anterior part, and the two protuberances meet and lie in 
contact in the middle, leaving an inferior and superior triangular 
space in the place of the original opening of the tube. Sometimes 
the external surfaces of the tnmora arc in contact for nearly the 
entire length ; and the only passage ia a small orifice below. The 
tumor may also grow from the upper surface of the tube, and, by 
gradually increasing in size, almost or quite fill up the passage. 
Two or more tumors, again, extend sometimes from various parts of 
the circumference of the meatus, and, converging towards the 
centre, fill up nearly the whole cavity. 

As far as my opportunities have permitted examination, these 
tumors, as in the one delineated below, appear to consist of ex- 



tbt reiileal aection of the External Mi 




, rroin witbont loirardii 



tremely hard and dense bone. In one case, where a portion of bone 
was denuded of membrane, it appeared shiny, white, and polished, 
like ivory. In 'another, where, under the raiaapprehension of the 
body being a polypus, caustic had been applied, the bone was ex- 
posed, and found to bo extremely hard and devoid of sensibility. 
In a third instance, where I observed the membrane to be absent, 



fe 



188 THE DISEASES OF THE EAR. 

there was a thin layer of cartilage on the surface, beneath which 
the bone was very hard. 

The tumors are usually covered by the lining membrane of the 
meatus, which is frequently thick, spongy, and less sensitive than 
is natural. When, by irritation, chronic inflammation is set up, 
this membrane pours forth a discharge whose odor is most oflTensive. 

The development of these tumors is frequently unattended with 
any symptoms calculated to attract the attention of the patient ; and 
therefore it is only when by their increase of size they act as an 
impediment to the passage of the sonorous vibrations to the mem- 
brana tympani, that the patient is inconvenienced by the deafness, 
and seeks relief. Deafness may result in these cases, first, from a 
collection of cerumen or epithelium lodging in and blocking up the 
small passage of the tube left unoccupied by the tumors ; secondly, 
a drop of water may have entered the ear during the ordinary 
ablutions, and produced the same effect ; thirdly, the growth of the 
tumor may have proceeded unchecked till the entire cavity of the 
meatus is filled up. In some cases, however, the growth of the 
tumors produces a feeling of distention in the ear, and weight in the 
affected side of the head ; while in others, again, they appear symp- 
tomatic of, and consequent on, exostosis forming in the deeper 
regions of the ears ; as, for instance, in the tympanic or vestibular 
cavities, — a condition I have sometimes detected in the course of my 
dissections. In three instances, subsequently cited, there seemed 
great probability of this being the case ; and the distressing noises 
and sense of giddiness may probably have depended upon the pres- 
sure exerted on the expansion of the auditory nerve by an exostosis 
in the vestibule. 

The only diseased substance with which the tumors are likely to 
be confounded, are polypi ; from which, however, by very slight 
attention, they may readily be discriminated. When inspected by 
means of the speculum, the polypus is seen to be darker in color, 
and glistening, from being generally lubricated by discharge ; the 
osseous tumor, on the other hand, is white ; and though smooth, free 
from moisture. The base of the polypus is also generally narrow, 
while that of the osseous tumor is broad. Any doubt, however, is 
easily removed by the use of the probe, which being pressed against 
the bony protuberance, at once reveals its nature. 

The disease under consideration mav be divided into two classes. 
The first and most common is that in which the disease appears 



THE EXTERNAL MEAT I' E. 



139 



associated with congestion of the mucous mcmbra.De of the ear. 
Moat of the patieots who have consuUed me on account of it were 
iu the habit of partaking freely of stimulating food and beverages, 

The second class showed Bymptoms indicative of disease in the 
cavities containing tho expansion of the auditory nerve. 

I will now proceed to point out some of tho modes of treatment. 
In those cases where the tumors occupy a considerable space in the 
tube, and the deafness depcndH upon the occlusion of the canal by the 
accumulation of cerumen or epithelium, it is important at once to 
remove it, and prevent future accumulations. Where water pene- 
trates into the orifice of the meatus, and fills up the only remaining 
pervious portion of the tube, wool should ho placed in the orifice of 
the meatus when the patient is washing. Should the membrane 
covering the tumor, as is not infreq^uent, be very thick, a certain 
degree of relief may be afforded by the application of remedies which 
shall reduce its sulistancc. In one case of this kind I was enabled 
to increase the size ^of the tube, and much improve the power of 
hearing, by applying a solution of nitrate of silver. 

In order to diminish the size of the tumor itself, after the avoid- 
ance of a stimulating diet, the best remedy is that usually employed 
by surgeons in osseous growths, viz., iodine. This medicine I have 
prescribed internally, and have applied it behind the car, and also 
to the surface of the tumors, with great advantage. In some cases 
large tumors wore so much reduced as to allow of the passage of 
sonorous vibrations ; and the patients regained in a measure that 
power of hearing of which they had for many months been deprived. 

If further experience should establish the fact that these tumors 
can be arrested in their progress, especially at that early period 
when the area of the tube is but slightly encroached upon, much 
good may be accomplished and much suffering prevented or relieved. 
And while there are many weighty objections to any attempt to re- 
move these tumors by operation or by escharoties, there are none to 
the use of iodine and the other absorbent medicines, from which 
there is every prospect, by persevering use, of successful results. 

In consulting authorities on this interesting subject, the only ob- 
servations I have met with in Kramer are the following : — 

" They (polypi) are even of cartilaginous and bony hardness. 

" A stalactite-shaped growth hung from the superior surface of 
the meatus, very near the membrana tympani, and was of so remark- 



140 THE DISEASES OF TUE EAE. 

able a bony hardness and lieiiBity, that it was impossible to pierce 
even with the sharpest knife."' 

Itard, although he states that the principal causes of the diminor 
tion of the external auditory meatus are the enlargement of the 
osseous, cartilaginous, and membranous structures forming the mea- 
tus, say a : — 

" I have never had an opportunity of observing the enlargement 
(ffonfiement) of the osseous part of the external meatus, and the ex- 
treme hardness which it possesses would tend to make this kind of 
alteration very rare."" 

Case I. Tumors in each ear, leilh deafness; tumors diminithed in 
me; deafness cured. — June, 1848 : T), N., aged 65, for the last 
few weeks has been feeling somewhat deaf, especially in the left ear. 
This deafness is increased by an attack of cold, to which the patient 
is subject. 

Riffht ear. — Meatus partly filled with bony growths ; one lisiog 
from the anterior, the other from the posterior part of the meatus. 
Membrana tympani dull. Hearing distance less than that of a 
healthy ear. 

Left. ear. — Meatus blocked up, except a small orifice, by three 
tumors which project from the walls of the meatus. The space left 
between tbeae-bony growths was occupied by a collection of cerumen, 
which being removed, the power of hearing, though still deficient, 
was to a certain extent improved. 

Considering that every attack of cold increased the deafness, and 
that the membrana tympani was dull, — a thickened state of the 
mucous membrane seemed also indicated, — the following course of 
treatment was adopted. Alterative doses of blue pill were admi> 
nistered, and the surface of the meatus was washed with a solution 
of argenti nitras, one drachm to the ounce, every fourth or fifth, and 
afterwards every seventh day. This course of treatment was con- 
tinued for three or four weeks, and the power of hearing was largely 
extended. The plan was resumed the following year, and the ulti- 
mate result was a perceptible diminution of the tumor, arising, as I 
believe, from a decrease in the thickness of the investing mem- 
brane ; and the power of hearing was completely restored, 

Case II, Tu7nor» in both ears ; deaf neas produced bi^ the presence 



THE EXTERNA!, MEATUS. 



oj a drop of water in the meatus. — July, 1846 : E. F., aged 60, liaa 
been so deaf in the right ear, for some years, as to derive little use 




ictiDg from tb« wftUs of Ihe Heatiu. 



from it. Has sereval times lately become suddenly so deaf in the 
left ear as scarcely to be able to bear a conversation. These attacks 




A largs Osfeoui Tumor and 



have usually come on in the morning after washing, and frequently 
lasted for some hours. 



142 THE DISEASES OF THE EAR. 

Right ear. — Two bony tumors were observed in the meatus, occu- 
pying about one-half of its calibre. Mcmbrana tympani dull. 

Left ear^ meatus. — Extending from the upper part of the meatus 
is a long bony tumor, taking up two-thirds its calibre. This tumor 
is covered by a thick soft membrane, excepting at one point of about 
half a line in length, and a quarter of a line in breadth. From the 
anterior and posterior parts of the low^er half of the tube projected 
two small elevations of bone, about three-quarters of a line in thick- 
ness, in the direction of the large tumor, so as to leave but a very- 
small triangular space between them. This space was the only open- 
ing by which the sonorous undulations could pass to the membrana 
tympani ; and it was found that, during the operation of washing, 
it was liable to be filled up by water, which produced temporary 
deafness. The opportunity of carrying out a course of treatment 
for the diminution of the tumors was not given to me ; but by adopt- 
ing means to prevent the entrance of water into the meatus, the at- 
tacks of deafness were entirely prevented. 

Case III. Tumor in the meatus of the right ear ; orifice in mem- 
brana tympani of left ear. — Nov. 13, 1845 : P. H., aged 56, eleven 
years before, when in Russia, fell asleep in a garden. The next day 
felt severe pain in the left ear, which lasted during fourteen days, 
when matter began to discharge. Has had several attacks of pain 
in the left ear since that period, which have been accompanied by 
beating and singing. 

About six months ago, being then in the West Indies, had an 
attack in the right ear, followed by a diminution in the power of 
hearing, but there was no discharge. Two months ago he returned 
to England, and entirely recovered the use of the right ear, hearing 
better also with the left. Within the last four days pain came on in 
the left ear and rapidly increased, followed by pain in the right ear, 
and so great an extent of deafness in both ears as to require him to 
be shouted to. 

liight ear, meatus extemus. — The middle two-thirds of the lower 
wall are occupied with a bony tumor filling half the calibre of the 
tube. 

Left ear. — Meatus extemus red, and covered by discharge. Mem- 
brana tympani white, soft, and thick, with a small orifice, through 
which air passes. 

Case IV. Osseous tumors in each ear ; feeling of confiision in the 
head. — ^Nov. 4^ 1848 : T. T,, aged 38. Last year deafness gradu- 



THE EXTERNAL MEATUS. 



143 



ally came on tn tho left ear, with occusioual attacks of deafness in 
the night. This deafness has of late very much increased, and been 
also attended with a feeling of confusion, and a sense of oppression 
in the bead. 

Right ear. — Projecting from the whole of the anterior and poste- 
rior surfaces of the external meatus, are two osseous growths, which 
come into contact in the centre of the tube. Hearing distance one 
foot. 

Left ear. — Two similar tumors likewise esist in the meatus of this 




ear ; but at the superior part they have so iucreascd as to be in con- 
tact throughout, save a small orifice at the lower part. The deaf- 
ness in this ear has been greatly increased by the presence of a small 
quantity of cerumen, which had filled up tho small orifice just de- 
scribed, and its removal gave temporary relief; but it was evident 
that the tumors would go on increasing until the entire passage of the 
meatus was blocked, unless remedial measures were at once adopted. 
For these no opportnnity was afforded me. 

Case V. Large tumor in left ear, causing deafne»»; diminished 
hy the me of iodine.— Veh. 1849. S. P., aged 17, states that deaf- 
ness commenced in the left ear, about two years and a half ago, 
and has been gradually progreaaing, till at length he cannot hear 
at all with that ear. Sometimes there is a violent itching, followed 
by discharge, and the tube of the ear is so sensitive, that the least 



144 



TUE DIBEABES OF TH 



touch cauEes exqnlsItG pain. There is also & continuously onplea- ) 
sant sensation, as if the ear were being distended. He complains 
of dulness of hearing in the right ear. Has been to various sur- 
geons and public institutions, hut without obtaining any relief. 
Right ear. — A large osseous tumor occupies nearly the whole of 

Fis. 12. 




the meatus, and is attached to its upper part. It is covered by the 
dermoid lining of the meatus, which is about a third of a line thick. 

Left far. — Healthy. 

Tincture of iodine was applied to the surface of the tumor, as also 
behind the ear, and four grains of iodide of potassium were giyen 
thrice daily for between two and three months. Great relief wa« , 
the result ; the size of the tumor diminished ; the power of hear- 
ing greatly increased ; the tube of the ear lost its unnatural sensi- 
bility; and the unpleasant sensation of distention completely va- 
nished. 

Ca»e VI. A ttimor in the right ear, filling nearly the entire tvhe; 
alight protuberances in the left ear. — Nov. 25, 1848 : J. S., aged 65, 
states that ten yoaj-s ago he had a gathering in the right ear, with 
great pain and much discharge. Continued, however, to hear pret^ 
well until within about a month previous to applying to me, during 



THE EXTERNAL MEATCS. 



145 



which he has grow-n so very doaf that he cannot hear, unless the 
speaker's mouth approaches close to the ear. 

Rigid ear. — The externa! meatus contained a collection of epithe- 
lium, on the removal of which an osseous tumor was disclosed, filling 
nearly the whole of the tuhe. The tumor projected from the upper 
and lateral surfaces, and nearly touclied the lower wall of the tube. 
Watch not heard in contact with the ear. 

Left ear. — The lower wall of the meatus presents two slight and 
quite hard elevations. 

Treatment. — Alterative doses of blue pills were prescribed, and 
tincture of iodine was directed to be applied behind the ears. The 
result I have not heard. 

Case VII. Tumor in the right ear following the extraction of a 
polypuK. — June, 1847: Rev. J. D., aged 47, consulted me for a 
continued discharge from the right ear. He stated tliat twenty 
years previously, after the forcible removal of a collection of wax 
from the right ear, he experienced great pain, followed by an offen- 
sive discharge, that had tasted to the present time. On examination, 
a large, red, and firm polypus was perceived to fill the whole of the 
meatus, nearly as far as the orifice. It was attached to the wall of 



Omww MMUr doralapod rrom ths 




I, iMTing B trlMtgulrv 



the meatus, near to the membrana tympani, and on its removal the 
latter was found to be very thick and vascular, with a small orifice 
at its lower part. The discharge wholly disappeared. 



146 



THE DISEASES OF THE EAR. 



In July, 185T, the patient again consulted me on accountu 
Blight return of the discbarge, accompanied by aome degree of paia 
in the right side of tbc head, with an unpleasant Bensation of fulness 
and pressure in the ear. On inspection, the meatus was found con- 
tracted to one-fourth ite natural size by the growth of osseous tn&tter 
from its walls, especially anteriorly and posteriorly, thus leaving a 
mere triangular opening, through which only the central part of the 
membrana tympani was visible, and that was white and thick. 

I recommended the use of a strong solution of lifjuor plumbi to 
stop the discharge from the tuhe, and the application of the tincture 
of iodine behind the ear. 

In this case there had been long standing disease of the tympanio 
cavity, membrana tympani, and meatus, consequent on local injury. 
The disease was attended with so great an amount of deafness, that 
it appeared as if the cavities containing the expansion of the audi- 
tory nerve might also be implicated. 

Case Vin. A protuberance of the lower wall of the meatus in the 
left ear. — December, 1848 : L. E. H., aged 25, ten years previously 
experienced a singing in the left ear, which during a cold became 
much worse, and was attended with a feeling of numbness. A cold 
has lately aggravated all the symptoms in the left ear, and called 
forth a noise like a bell in the right ear. 

Right ear. — Membrana tympani dull ; hearing distance two feet. 
Jjeji ear. — Meatus contained a large quantity of cerumen, after 
the removal of which the passage was observed to he red. At the 
lower wail near the membrana tympani there is a considerable bulg- 
ing of the OBseoua wall. Hearing distance half an inch- 
In this case the diminished degree of hearing in the left ear did 
not depend upon the enlargement of the external meatus, for there 
was no doubt of a thickening of the mucous membrane lining the 
tympanic cavity. 

Case IX. Oeseous tumor in the external meatus, causing a collee- 

I Hon of epidermis and serious cerebral symptoms; relieved. — J. J. S., 

} Esq., aged 56, consulted me on the 27th April, 1850. He stated 

that when a boy he had a discharge from the right ear, since which 

period he has been deaf at times, and been subject to a noise in the 

ear, together with a feeling of pressure on the head. Two months 

ago he complained of an attack of toothache, during which the dcaf- 

3 was partially relieved ; but lately it has become worse again, 

;ompanied by a feeling of pressure in the ears ; he has also had 




THE EXTERNAL 



147 



frequent attacks of giddiness and confusion in the head. On exa- 
mining the right ear, the middle part of the meatus was seen to be 
occupied by a bony tumor which fills the whole of the tube, with the 
exception of a, small space about three-quarters of a line in diameter, 
ftitnated at its superior part. This space was observed to be closed 
by a white substance, which, on being touched with the probe, proved 
to be of great density. As it appeared probable that part, at least, 
of the symptoms above detailed depended upon the collection of epi- 
dermis behind the bony tumor, and its pressure upon the membrana 
tympani, it was thought desirable to attempt its removal. Small 
portions were picked away by the point of a probe, and the syringe 
was used ; it was, however, so hard that only minute particles could 
be detached. A solution of carbonate of soda was directed to be 
applied constantly for some days, and then a further quantity was 
extracted, which mitigated the symptoms. By pursuing this plan, 
the whole of the matter beyond the tumors, which was found to be 
epidermis, was got rid of ; and the patient not only heard better, 
but the unpleasant symptoms of giddiness and cerebral irritation 
entirely disappeared. Judging from the large quantity of epidermis 
removed in comparison with the small space between the tumor and 
the membrana tympani, that substance must have been greatly com- 
pressed, and the membrana tympani also subjected to much pressure. 
In the year 1852, and again in the present year, the same gentle- 
man consulted me on account of similar symptoms, which were wholly 
removed by the use of the syringe alone. 



II, M0LLLSCOU.S Tumors. 



Molluscous tumors are sometimes formed in the external meatus, 
and lead to very serious results. I first met with these tumors when 
making dissections of the ear, and several speciraens are in my 
possession, which well illustrate the nature of the disease. These 
excrescences seem to have their origin in the dermis of the meatus, 
and they gradually increase in size so as not only to fill the whole 
of the meatus, but to encroach upon and cause absorption of the 
bone. Thus, in some instances, the lower osseous wall of the 
meatus is affected, and in part absorbed, while in others the tumor 
extends upwards, and the whole of the upper wall of the meatus 
effaced by the pressure exerted upon it. I have met with coses 



1-18 



THE DISEASES OF THE BAR. 



which the tumor has extended into the cerebral cayity. 
cases are liable to be overlooked, and classed with those ii 
there is a simple accumulation of epidermis in the meatus. 




.■ of (he MCBJUE Ell< 



The treatment of molluscous tumors consists in removing tfaol 
large mass of scales contained in the tumor, and afterwards syringing 1 
the meatus abundantly with warm water twice or thrice daily. 




hiu) been removeil. 



Cote. MnlluKoiit tumor in the external meatut ; dhcharge from 
..he ear. — Mr. G., between 40 and 50, consulted me for a diaeharge 



THE EXTERNAL MEATUS, 



149 



from the right ear, accompanicJ by deafncsa. On examination, the 
meatus was observed to be nearly full of a white caseous-looking 
matter, from which oozed a discharge. By perecvering use of the 




IF wall o{ tbe MmtUB EiUroua flpn 
CavitT, prodaced b; a MoUdb 



.ting wilh the Csrcbrsl 



syringe, aided by the forceps, a large white mass was removed, 
which was found to consist of layers of white matter, composed of 
large scales, similar to those of other molluscous tumors. On the 
removal of the mass the discharge disappeared. 

In bringing to a conclusion these observations on the diseases of 
the external meatus, it wilt be well to draw attention to the morbid 
conditions disclosed by the disBection of 1013 diseased ears. They 
were as follows : — 



CoDtsinlDK acolleatiun of acrumen. 

ConUining a ooUtolion of cerumen ind epidermis 

Diitendwl Bod dUal«d b; ft coUeotioD of oerameo, ..... 
IKeteBded and dilated b; a aoUeclion of Beramen and epidermii, . 

Containing a CDlleotion of oerumea and r;c-»edi 

CoDtaining a cOlleDtlon of oeniman, tbe oueoiu walla being abiorbed in 

CankainingacollecliDD of cernmeD and epidennla, the oanant walls being 
kbtoTbed In parte, 

ContaiDlng a CDlleoCIon ot cerDmnn. the osReoae walls being abaorh«d in 
parti, >o a> to eipow tbe oavitiei of ibe loutoid ceiln. 

Containing a colleetion of haiiK 

Containing s eoUeotioa of ootton-woal, 



150 THE DISEASES OF THE EAR. 

Containing a molluacoas tamor, 5 

Containing a moUusoous tamor, the osseoas wallB being absorbed in 

parts, 3 

Containing a mollasooas tamor which projects through the bone into the 

cerebral cayity, 1 

Containing a mollascous tamor which projects into the mastoid cells, 1 

Containing a collection of pas, 10 

Containing a collection of pus mixed with epidermis, .... 1 

Haying polypi growing from its walls, 1 

Haying polypi growing from its walls, the bone being oarioas, . . 1 

The dermoid layer so much atrophied as to leaye the bone denuded, . 2 

The dermoid layer hypertrophied, 2 

The dermoid layer congested, 7 

The dermoid layer soft 1 

The dermoid layer soft and red 2 

The dermoid layer soft and detached from the bone, .... 2 

The dermoid layer soft and thick, the bone being oarioas, ... 1 

The dermoid layer ulcerated, the bone being carious 1 

Osseous walls rough, 1 

Osseous walls carious, 7 

Osseous walls absorbed in parts, 2 

Osseous walls presenting an orifice superiorly, 3 

Osseous walls presenting an orifice inferiorly, . . .... 1 

Osseous canal much contracted 3 

Haying bony growths from the osseous walls ; canal much contracted, . 14 



CHAPTEK VIII. 

THE MEMBRANA TYMPANI. 
BTRtJCTDRB AND FDKCTI0S8. 



Anatomical Observations. — There are bo many points of interest in 
Pathology connected with the structure of the membrana tympani, 
which bear upon its morbid conditions, but which have not hitherto 
been sufficiently recognized, that the subject deserves a full exami- 
nation. Looked at from without inwards, the membrana tympani 
may be described aa consisting of the following layers : — 

1. The epidermis. 

2. The dermis. 

3. The fibrous layer, composed of — 

a. The lamina of radiating fibres. 

b. The lamina of circular fibres. 

4. The mucous membrane. 

The epidermis is a thin layer, covering the outer surface of the 
dermoid lamina ; it is continuous with the epideimis of the external 
meatus, and, when subjected to the process of maceration, can be 
removed in the form of a small Mind pouch, which presents, as it 
were, a cast of the meatus and of tie external sm-face of the mem- 
brana tympani. "When floating in water, the pouch reassumes the 
form it had when in contact with other tissues, and its internal 
extremity is convex, corresponding with the external concavity of 
the membrana tympani. The layer of epidermis forming the outer 
coat of the membrana tympani is thin, and in the living subject so 
transparent that the dermoid layer can be distinctly seen through 
its substance ; its outer surface is very smooth, and capable of re- 



152 



THE DISEASES OF TUE EAR 



fleeting light ; and there 19 Dsually Bcen at Its anterior and inferioi 
part, a triangular shining spot. 

In the course of diBaection, I have more than once found thisi) 
delicate epidermis to be the only layer remaining, over portions vary- 




MBmbrana Tjmpniil. 



ing from a line to a line and half in breadth, and yet appearing to 
have been sufficient to close the cavity of the tympanum and to pre- 
serve the power of hearing nearly perfect. The knowledge of this 
condition of the membrana tympani ought to lead to a cautious use 
of the syringe when no cerumen ia present, since its application m»y 
cause a rupture of the epidermis. 

The dermoid layer, as its name implies, is continuous with the 
dermis lining the external meatus, and is situated between the epi- 
dermis and the radiate fibrous layer. It is extremely thin, and 
secretes the epidermis. Previous to the publication of a paper by 
me on the structure of the mcinbrana tympani, in the " Philosophi- 
cal Transactions," for 1851, it bad been supposed that the epidermis 
was secreted by the radiate fibrous layer. The presence of the der- 
mis is best demonstrated by carefully dissecting, under water, the 
membranous meatus from the upper surface of the osseous tube, as far 
as the attaohmept of the membrtina tympani ; at which point the peri- 



THE MEM BR AN A TYMTANr. Ibd 

OBteom of the meatus is seen to become continuous vrith the radiate 
fibrous lamina ; this being cut tbrougb, tlie dL'rmoid layer is detected 
passing down over tbe outer surface of the radiate fibres, and sepa- 
rating them from the epidermis. If the upper portion of this layer 
be drawn gently downwards by one hand, by means of a fine needle 
in the other, tbe delicate cellular tissue which connects it with the 
fibrous lamina can be broken up, and the dermis removed entire. 
The presence of thia lamina may also be shown by introducing be- 
tween it and the radiating fibrous Inycr, at the superior part of the 
memhrana tympani, a fine bristle, by passing which down the cel- 
lular tissue is lacerated. 

In a healthy state, when uninjected by blood or by artificial 
means, the dermoid lamina la thin and transparent, and its structure, 
under tbe microscope, looks like areolar tissue. When injected, 
however, this membrane is seen to have numerous bloodvessels rami- 
fying through it, so as to form an elaborate plexus : these vessels, 
when enlarged, impart the red appearance to the surface of tbe mem- 



The Dermoia Lajs r 




brana tympani so frequently met with ditring life. It is upon the 
supply of nerves to this lamina that the exquisite sensibility of tbe 
memhrana tympani depends. 

A knowledge of the existence of the membrane just described is 
of interest to the anatomist, who recognizes in it the secreting organ 
of thfe epidermoid layer of the membrana tympani ; and to the sur- 
geon, who through its presence is enabled to understand phenomena 
occurring in certain diseases of the ear. There are peculiar diseased 
conditions in which the dermoid layer of the membrana tympani be- 
comes much hypertrophied. 

The proper Jibroua layer of the memhrana tympani can be easily 
separated into two lamince, which are named from the direction of 
their component fibres. Previous to dcBcribing these structures, it 



154 



OF THE EAR. 



13 desirable to cite the opinions of eminent anatomists concenung 
them. 

In the Croonian Lecture, published in the 19th volume of the 
"Philosophical Transactions," Sir Everard Homo advanced the 
opinion that the mi?mbrann tympani in the human subject was mus- 
cular. His words are: "When viewed in a microscope, magnified 
twenty-three times, the muscular fibres are beautifully conspicuoos, 
and appear uniformly the same throughout the whole surface. There 
being no central tendon as in the diaphragm, the muscular 6bres 
appear only to form the internal layer of the membrane, and are 
most distinctly seen when riewed on that side."' The use of tliis 
radiated muscle, Sir Everard states, is " to give those different de- 
grees of tension to the membrane which empower it to correspond 
with the variety of external tremors."* Since the first publication 
of this opinion as to the muscularity of the membrana tympani, ana- 
tomists, though generally conceding that it is fibrous, have widely 
differed aa to its composition. According to Mr. Quain and Dr. 
Bharpey, " It is made up of fine closely-arranged fibres, the greater 
number of which radiate from near the centre to the circumference; 
but within these are circular fibres, which are more scattered and 
indistinct, except close to the margin of the membrane, where they 
fcform a dense, almost cartilaginous ring."' Mr. Wharton Jones 
writes : " The proper membrane can he divided into two layers — an 
outer thin one, consisting of radiating fibres, and an inner thicker 
layer, which is less distinctly fibrous, though when torn it does indi- 
cate a fibrous disposition, and that in a direction opposite to the 
former. , . . The fibres which cross tho radiating ones are more 
aggregated at the centre ' they run parallel with the handle of the 
malleus, and turn round its extremity. At the circumference of the 
proper membrane, there is a thick, firm, ligamentous or cartilaginous 
ring, which is fixed in the groove of the hone. The ligamentous 
ring appears to be formed by an aggregation of the circular fibres 
interwoven with the peripheral extremities of the radiating ones."* 

By careful dissection the fibrous layers of the membrana tympani 
may he separated into two distinct laminse, the fibres of which have 
no intercommunication. The external layer may be called the radi- 
ate fibrous lamina, since its fibres radiate from the malleus to be at- 

' Loo. oit. p. 5. • Loo. oit. p. 11- 

■ ElimciitB of AaBtotn;, Stb Edition, 1S4S, vol. ii. p. 93S. 

■ Cyolopmlitt of Aostomy ud Phjaiolog;, tdI. ii, p. £45. 



THE MEMBRANA TTMPANI. 



155 



taelied to the cartilagiaouartDg; anil the uitema.], the circular fibrous 
lamina. The radiate layer is the thicker and stroDger of the two. 
So readily may the layers be separated from each other, that they 
are detached with more facility than the circular layer can he freed 
from the mucous membrane. 

(a.) The radiate fibrous layer. — If the whole of the membrana 
tympani be carefully removed, there will be observed at its cir- 
cumference a white, dense ring, apparently cartilaginous, which is 
received into the osseous groove of the temporal bone appropriated 
to it. It will be remembered, however, that this groove occupies 
only about five-sixths of the circumference of the inner extremity 
of the meatus, the upper sixth being smooth instead of grooved. 
The cartilagiuous ring at tlie upper part is attached to the malleus, 
the anterior extremity being inserted into the anterior, and the pos- 
terior extremity into the posterior, part of the cervix of this bone: 
to the outer surface of this ring is attached the periosteum lining 
the external meatus. If the radiate lamina be examined with a 
magnifying power often or twelve diameters, fibres will be observed 
whose peripheries are attached to the cartilaginous ring, and their 
other extremities to the malleus. The uppermost of these fibres, 
however, must be excepted from the observation just made ; for in- 
stead of passing from the superior part of the ring to the malleus, 
they take their course in front of the processus brevis, and form a 
distinct layer of membrane covering its outer surface. The dispo- 
sition of this portion of the radiating fibrous lamina is interesting 
alike to the anatomist and surgeon, for it is observed to be con- 
tinuous with the periosteal lining of the upper part of the external 



The Radiate Fibi 



lA Tjrmpajii. 



meatus. Mr. Shrapncll, perceiving that this portion of the mem- 
brana tympani was not so tense as the rest, considered it to be a 
distinct structure, and named it the " membrana fiaccida." 

Directly below the processus brevis of the malleus, the radiating 
fibres are attached to the ridge occupying the external surface of 



156 THE DISEASES OF THE BAR. 

the bone ; but at this part the fibres from each half of the mem- 
braDa tympani are inserted so near to each other that do portion of 
the malleus is visible when vicved exteriorly. Towards the inferior 
extremity of the long proceBs, however, the fibres being attached to 
the sides and not to the anterior surface, a small portion of the ex^ 
temal surface of the long process, at its inferior part, is left bare 
and in contact with the dermoid layer ; as may be distinctly seen in 




The Fibree eoinpoiiDg tbe Radiate Fibrous I.siiuna (msgnifled about 300 diunatera) .* 

the healthy living ear by the aid of the speculum auris and a mag- 
nifying lens. The fibres extending from the malleus, and forming 




Tha Radiate Fibroni LaminiL ; <it«rnal lurface displaying th« peculiar muluDgl ransed 
b; the interlacement of the Bbiee. 

the posterior, arc one-fourth larger than those forming the anterior 

segment of the membrane. The thickest part of this layer sor- 



' In th* other dmriugs tront the mlcronope, the u 



• magnifying power iru atad. 



THE MEMBRA 



TYMPANI. 



157 



8 the extremity of the long process of the malleus, and the 
most attenuated lies between the posterior miu-gia of the long pro- 
cess of the malleus and the circumference of the membrana tym- 
paoi. 

Structure of the radiate lamina. — The fibres composing the ra- 
diate lamina, when examined in a fresh state by the microscope, are 
translucent, and, with the exception of a few transparent globules, 
present no peculiarity of structure. The longitudinal parallel wavy 
lines, however, characteristic of ordinary fibrous membranes, are 
absent. The fibres arc flat, and vary from t^aa to eo'ob of "^n 'ich 
in breadth. In passing from the circular cartilage to the malleus 
these fibres interlace, giving rise to the peculiar diamond-shaped 
markings observable on the outer surface of the membrane. When 
treated with acetic acid, this lamina becomes opaque, and sometimes. 



The Sadiata Fibroiu Lunlun. wtlet luring 




Iraatcd nilh Acttlo Ae'ul. 



but not invariably, elongated oval nuclei are detected, the long axes 
of which correspond with the course of the fibres. In no instance, 
however, was an oval nucleus visible in an isolated fibre, 



Tha CiTcnl&r CartilagiDona Band, afUr baring b«n treated by Acetic Acid, 

The circular white band at the circumference of the radiate fibres 
consists of a firm, slightly elastic mafls of tissue, and presents an in- 
distinct appearance of fibres interuiixed with oval-shaped nuclei. 



158 



THE DISEA 



Under acetic acid this structure lost's its wLitc aspect, becomes I 
translucent, and discloses a great number of the oval nuclei. 

(i.) The circular fibrous laviina. — Tbis membrane, as previously 
stated, is attached to the radiating fibres by fine cellular tissue, and 
can be readily separated ; for, as before observed, the fibres of each 
lamina are quite distinct and never intermingle. As its name im- 
plies, this lamina consists of circular fibres, which are firm and 
strong at the circumference, but so attenuated towards the centre, 
as to be detected only by careful observation. The strong fibres at 
the circumference of the layer form a complete circle, and are at- 
attachcd to each side of the body of the malleus, and to the sides of 
the upper third of the processus longus. When closely examined 



^^ 



Tba EitcmiJ Burfue at the CiroolHr Fibrous Luninn lbs Bbrea being sttBchnd In 
tbo Proc^snu Longiu of th« Malleus. (Slightly niBgnifled.) 



by a magnifying power of thirty to forty diameters, the circular 
fibres are seen to be intersected by others of an extremely delicate 
character, which, increasing in number towards the centre of the 
lamina, become there so intimately blended with the circular fibres 
that the latter are not easily distinguishable. The central thin por- 
tion of the circular lamina is not attached to the malleus, but the 
fibres from each side are continuous, and form a membranous layer 
by a series of concentric fibrous circles ; the outer surface being in 
contact with the inner surface of the lower half of the long procese 
of the malleus, to which it adheres by loose cellular tiBsuo. The 
circular fibrous lamina is entirely unconnected with the cartilagi- 
nous ring into which the radiating fibres are inserted ; but is con- 
tinuous with, and may be considered a modification of, the periosteal 
lining of the tympanic cavity. When the lamina of circular fibres 
is detached from the radiating layer, it will be found slightly con- 
cave externally, though less so than the outer layer. In its sepa- 
rate condition it is also not quite so concave as when il was con- 
nected with the inner surface of the radiating fibres; but when its 
central portion is pressed inwards, so as to increase the concavity, 



THE MBMBRANA TVMPANI. 



itB inherent elasticity causes it quickly to resume its former saucer- 
like shape. If the two layers, when detached, be placed side by 



side, the greater degree of external concavity in the radiating 
fibrous layer is Yery perceptible. 

Structure of the circular lamina. — When highly magnified, the 
fibres of the circular lamina are found to be smaller than those of the 
radiate fibrous layer, and to vary from the 6000th to the 10,000th 
of an inch in breadth. The outer fibres run parallel with each other, 
and do not interlace ; they are diaplionous, and free from any wavy 
longitudinal lines. Under acetic acid, the fibres enlarge and a 




The Fibres oompomng tbe Oinnlar Fibrotu Ltmina. 

a certain degree of opacity ; and in some instances this lamina also 
presents distinct oval nuclei elongated in the direction of its fibres; 
but as in the radiate lamina, never in the separate fibres, and most 
commonly they are not present. 

It is often not easy to decide whether a structure is muscular : 
hence doubts may arise as to the true nature of the two fibrous 
laminie of the membrana tympani. My own researches do not seem 
to favor the view of that membrane being a contractile tissue. The 



160 THE DISEASES OF THE EAB. 

facts vhicK appear to militate against the idea of its being muscu- 
lar, are : — 

1st. The absence of distinct nuclei in the fibres. 




Tb« Fibrai of th« Ciroalu Fibroiu LimiDO, trsstsd with AmUo Aoid. 



2d. The great denseness and hardness of the latter, and their firm 
and unyielding structure, they being so strong as to be with diffi- 
culty torn across. 

(c.) The mucous membrane forming the inner layer of the mem- 
brana tympani is, in the healthy ear, so extremely thin as to be with 
difBculty detected ; though by careful dissection it may be removed 
entire from the inner surface of the circular fibres, with which it is 
connected with considerable firmness by fine cellular tissue. 

It will now be evident that of all the lamina which constitute the 
membrana tympani, Dot one is proper to that organ ; all of them 
being directly continuous with other structures, of which they appear 
to be modifications. Thus : — 




The Radiali Fibroni L]Un!n^ the Circutii FibiDui Lamina, tnd tfaa Hnoona Membrane of 
the HembraDB TjropBni, nen to be coDtinnoiu with the other itraotntM. <Slightlj 
magaifled.) 

Ist. The epidermis is coatinnous with that lining the external 
meatus. 

2d. The dermis is contiouous with the dermis of the meatus. 



THE MEMBRASA 



161 



3tl. The fibrous lamina consists of the radiate fibrous lamina, 
which is a prolongation of the periosteal lining of the external 
meatus; and the circular fibrous lamina, a prolongation of the peri- 
osteum of the tympanum. 

4tli. The layer of viucous mcmhraiie forms part of the lining of 
the tympanic cavity. 

Previous to considering the functions of the fibrous laminie of the 
mcmbrana tympani, it is desirable to advert to another point in the 
structure and relations of this organ. It has been already stated 
that the membrana tympani is attached, at its circumference, to tbe 
temporal bone, and, at its central part, to the malleus, which latter 
bone is so suspended by means of the processus gracilis and tliv 
short process of the incus, that tho long process can move inwards 
towards the tympanic cavity, and outwards towards the meatus. It 
must be evident, therefore, that in order to prevent the concave 
membrana tympani, with the above attachments, from remaining in 
a state of relaxation, either the tensor tympani muscle must be in a 
state of continual contraction, or some other provision must exist 
for retaining the membrana tympani in the moderately tense con- 
dition fitting it to receive the sonorous undulations. This provision 
actually exists, and, as far as I am aware, has hitherto escaped the 
attention of anatomists : it is the tensor ligament of the mettibrana 
ttfmpani. 

The ligament in question is about three-fourths of a line in length, 
and is attached internally to the cochleariform process, and exter- 
nally to that part of the inner surface of the malleus where the long 
process joins the neck. In the interior of this ligament, which 



I 




Til* AttachnenU ol tba Ten 



is tubiform, is placed the tendon of the tensor tympani muscle. 
Anteriorly the ligament is thin, consisting of very delicate fibres; 
but the remainder is thick, dense, and composed of firm ligamentous 



162 THE DISEASES OF THE EAB. 

tissue. So long as it remains entire and the membrana tympani 
uninjured, the latter structure retains its natural degree of con- 
cavity and tenseness; but when the ligament is cut through, or 
there is a solution of continuity, resulting from disease, the mem- 
brana tympani becomes very flaccid, even though the tendon of the 
tensor tympani muscle remains entire. When the tensor tympani 
muscle is pulled, in a preparation of the parts, the membrana tym- 
pani is rendered very tense, and the tensor tympani ligament re- 
laxes; but so soon as the muscle relaxes, the membrana tympani 
returns to its original state, and the ligament again becomes tense. 

On the functions of the fibrous lamince of the membrana tympani. 
— It is obvious that one use of the fibrous laminae of the membrana 
tympani is to present a firm but delicate membranous septum for the 
reception of sonorous undulations. The arrangement of the two 
sets of fibres at right angles to each other, has the effect of impart- 
ing great strength, combined with extreme delicacy and tenuity, to 
the membrane. As stated, there is no evidence to prove that the 
fibres of which the membrana tympani is composed possess in them- 
selves any contractile power ; neither do the component fibres of the 
laminte appear to evince more than an extremely slight degree of 
elasticity. An examination, however of the structure after death, 
shows that it has an inherent power of returning to its natural state 
after being unusually distended. Thus, if the membrana tympani be 
exposed without interfering with its natural state of tension, and the 
canal containing the tensor tympani muscle be laid open, so that the 
muscle can be drawn towards its origin, the external concavity of 
the membrana tympani can be increased until it becomes very tense ; 
but as soon as the muscle is let go, the membrana tympani will be 
observed to resume its former condition. This action is explainable 
partly by the slight elasticity of the circular cartilaginous band, into 
which the peripheral extremities of the radiating fibres are inserted, 
and partly by the slight elasticity of these fibres themselves ; but more 
especially by the peculiar arrangement of the circular fibrous lamina, 
which has always a tendency, when left to itself, to assume a more 
shallow form. Thus when the membrane is rendered very concave, 
the circular fibres are slightly separated from each other ; but when 
the extra tension ceases, the fibres intersecting the circular ones aid 
in drawing the latter together again. 

The disposition of the central region of the circular lamina also 
assists it in bringing back the membrana tympani to its natural 



TOE MEMBBANA TYMP 



163 



> after tension by the tensor tjmpani muscle. It has been 
stated that the miilille part of these circular fibres, instead of being 
attaebcd to the handle of the malleus, is applied against its inner 
surface, and thus the membrane is further rendered tense by the 
pressure of the long process of the malleus against its outer surface 
during the action of the tensor tympani muscle; and when this 
muscle ceitaea to act, the central part of the circular layer reacts on 
the malleus und constrains it to resume its usual position. Bestdoa 
the office of bringing the memhrana tympani to its natural state 
after the action of the tensor tympani muscle, the circular fibrous 
layer would appear to be always acting as an antagonist to the 
tensor tympani ligament ; so that by the continued action of these 
two tissues — the one drawing it inwards, the other outwards — the 
membrana tympani is kept in a state adapted to receive all the ordi- 
nary sonorous undulations, independent of any exercise of muscular 
power. 

Tk« functionK of the iTiembrana tympani. — Anatomists generally 
consider that the use of the membrana tympani is to receive the 
sonorous undulations from the air of the meatus, and conduct them 
to the ossicles, by which they are conveyed to the labyrinth. 
Whether vibrations are conducted to the labyrinth through two 
media, or through the air alone, there can be no doubt that the 
membrana tympani is the agent whereby the vibrations are con 
veyed from the meatus externua to the tympanum. I shall, in a 
future part of this volume, try to prove that another function of the 
membrana tympani is, in conjunction with the muscles and bones of 
the tympanum, to act as the analogue of the iris of the eye : and 
thus, firstly, shut out from the internal car, or at least modify, the 
effect of loud vibrations ; and, secondly, render the ear susceptible 
of the more delicate undulations. 

Whatever opinion may be held respecting the functions of the 
membrana tympani, there can be no doubt that its integrity is 
essential to the due performance of its functions, as also that it 
should retain its natural degree of resiliency, and that its muscles 
should be able to move it with ease. 




THE HEMBRANA TYMPANI (wnlimifd). 



Is describing the diseases of the membrana tympani, I shall speak 
in sDcceasion of its cpidermmd, dermoid, and fibrouB lajors, leaying 
the consideration of the mucous layer till the diseases of the 
panic cavity come under review. 

I. The Epidermoid Layer. — Tliis layer is sometimes secreted in 

I Bncli large quantities as to form a mass several lines in thickneu 

on the outer surface of the dermis. In some cases I have knoint 

this mass to be composed of six or seven laminie, closely packed 

upon each other. The symptoms attendant upon this acctunulatioii 



EpiilBrmoid htjn of (he Membrnaa Tyuipaoi hjrfitttrbpbiecl, (MagDified three diamt 

are analogous to those of accumulation of epidermis In the meatus ; 
there is also often a great degree of cerebral irritation from the pres- 
sure on the chain of ossicles. The treatment is similar to that em- 
ployed where there is accumulation of epidermis in the meatus exter- 
nas. A syringe and wurm water are usually sufficient to loosen and 
bring away the mass. Should they not be so, a few drops of water 
or soap and water, dropped into the meatus for a day or two, will 



TH£ MEMBRA 



TTMPANI. 



165 



loosen and facilitate the removal of the mass. As a general rule, 
the symptomB of deafness and discomfort in the head wholly dis- 
appear with the extraction of the collection. 

II. The Dermoid Layer. — This layer of the mcmbrana tympan!, 
like the dermis of the meatus, is subject to acute and chronic inflam- 
mation, and also to ulceration. On account of the intimate relations 
existing between the dermoid and fibrous layers of the mcmbrana 
tympani, it is of great importance to put a atop to these affections 
of the dermis, since they are apt to be prolonged to the deeper- 
seated layers of the organ. 



(a.) ACUTE INFLAUHATION OF THE DSRMIS. 



Acute inflammation of the dermis usually occurs in debilitated 
subjects, and is produced by the application of cold, or cold water, 
or any foreign body to the surface. The exciting causes are sudden 
exposure to cold air after being in a warm room, or cold water find- 
ing its way into the ear while bathing ; often also it arises from the 
extension of inflammation from the dermis covering the meatus. 
The symptoms of this kind of inflammation are slight pain at the 
bottom of the meatus (aggravated by coughing, sneezing, and at 
times by swallowing), also not unfrequently an itching, with slight 
duInesH of hearing. On examination, the outer surface of the mem- 
brana tj-mpani is seen to be dull, and the dermoid layer opaque; its 
bloodvessels being distended with blood. All the vessels bordering 
on the malleus are very much larger than natural, and frequently 
form two red lines, oue running on each side of the long process of 
the malleus. After a few days a discharge of mucus often takes 
place. This aff'ection, if left unsubdued, is apt to advance to ulcera- 
tion, and the fibrous layers are also liable to be destroyed. 

Treatment. — The treatment is very similar to that for acute in- 
flammation of the dermoid meatus. One or more leeches should be 
applied to the margin of the orifice of the meatus, warm water should 
be syringed into it thrice or oTtener daily, hot fomentations used all 
around the ear, and, if requisite, aperient medicines and calomel ad- 
ministered. Most usually the inflammation (seldom accompanied 
by discharge, though a small quantity sometimes issues from the 
surface of the membrane) soon succumbs to this treatment, and the 
fibrous laminae escape uninjured. 



166 THE DISEASES OF TUE EAB. 

Case I. Acute inflammation of the dermoid layer of the memhrana 
tympani, — G. W., Esq., aged 60, consulted me on February 15th, 
1853, on account of pain in his right ear. 

History. — Without assignable cause, slight pain occurred in the 
right ear several days ago, which has remained till now, being aggra- 
vated at times. It is increased by coughing, and slightly when swal- 
lowing. A sensation of fulness is also complained of. On examinor 
tio7tj I found the dermoid layer of each memhrana tympani to be 
more opaque than natural, and numerous bloodvessels, especially at 
the upper part, were observed to be distended with blood. There 
was but slight diminution in the power of hearing. 

Treatment. — As the pain was not very severe, the ear was ordered 
to be syringed out with warm water twice daily, a linseed-meal poul- 
tice to be applied over the ear at night, and a stimulating liqoid to 
be rubbed over the back of the ear. The pain gradually ceased, and 
the membrane returned to its natural state. 

Case II. Acute inflammation of the dermoid layer of the memhrana 
tympani. — B. S., Esq., a medical man, aged 48, saw me in February, 
1852. 

History. — When a student, twenty-six years previously, he had 
an attack of cold, and became suddenly deaf in both ears, but re- 
covered in the course of two months. Sixteen years ago, had an 
attack of vertigo, and suddenly lost the use of the left ear ; the 
hearing partially returneil, but still remains dull. A fortnight be- 
fore consulting me, he had relaxation of the throat, with an uncom- 
fortable feeling in the left ear, and again became dull of external 
hearing, though the sound of his own voice was like thunder. On 
examinatiofu the memhrana tympani was observed to be swollen and 
much redder than natural : its bloodvessels being large and dis- 
tended. Watch heard at a distance of two feet. 

Treatment. — Slight counter-irritation was kept up behind the ear, 
and a cooling lotion applied to the meatus for ten days ; at the end 
of that time the patient quite recovered. 

Case III. Aeute inflammation tf the dermoid layer of the mem- 
hrana tympani. I>isehanfe ef viseid mucus. — Master S., aged 8, 
was brought to me by his father, a physician in London, on the 19th 
April, 1853. 

History. — A few days previously, when not feeling very well, com- 
plained of slight pain in each ear, which continued for two days, 
and was followed by a discharge of mucus, with slight dulness of 



THE MEMBRANA TYMPANI, 107 

hearing. The latter symptoms have remainod until the present 
time. 

On examinatiov, each external meatus was obaeryed to be par- 
tiallj filled with matter, which was removed by the syringe, and 
found to he composed of masses of mucus, similar in character to 
those issuing from the meatus in eases of acute inflammation of the 
dermis. They were more floeculent, whiter, but not so elongated as 
in the secretion from the mucous membrane of the tympanum. After 
the meatus had been cleansed, the outer surface of the memhrana 
tympnni was seen to be of u deep red color, and to project outwards 
into the cavity of the meatus. More minute inspection showed that 
this red appearance depended upon the tumefaction of the dermoid 
layer of the membrane, which being denuded of epidermis, the pro- 
cessus brevis of the malleus was observed at it,"! uppermost part. 
The hearing was very dull. 

Treatment. — A leech was ordered to be applied to the margin of 
the orifice of each meatus, and hot poultices to be kept over the ears. 
By these means the pain was subdued, and the inflammatory symp- 
toms abated. In the course of three days a small portion of vesica- 
ting paper was applied behind each ear. The power of hearing re- 
turned by degrees, the discharge disappeared, and the dermoid mem- 
brane regained its natural appearance. 

Case IV. Acute infiamination of the dermoid layer. Secretion of 
mucus. — A. Moorman, aged 68, was admitted under my care at the 
St. George's and St. James's Dispensary, on May 24th, 1850. 

History. — During the last five months has felt much debilitated. 
About seven weeks previous to seeing me, pain suddenly attacked 
the right ear, and was followed by a. " steaming and hissing sound." 
After this sound had remained for three weeks, a discharge issued 
from the ear, which has continue<i to the present time, accompanied 
by a good deal of itching, and by a sensation as of something grind- 
ing within the ear. On examination, the watch was only hoard when 
in contact with the ear ; the dermoid layer of the membrana tym- 
pani was observed to he flat, red, and very much swollen ; and there 
was a watery discharge, consisting principally of epidermoid cells. 
The surface of the meatus was rather redder than natural. 

Treatment. — The ear to be syringed with warm water twice daily ; 
and vesicating paper to be applied each night behind the ear. 

May 31. — Better ; the noise less loud ; the power of hearing in- 
creased. 



168 TUE DISEASES OF THE EAR. 

Juno 7. — Improves daily : the quantity of discbarge is mncli 
diminished; and the noises have ceased, with the exception of short 
occasional attacks. The membrana tjmpani is recovering its natural 
aspect. 

(S.) SIMPLE CHRONIC INFLAMMATION OF THB DKBMOID LATBE, 
WITH OR WITHOUT AK ACCDMULATIOK OF EPIDERMIS. 

This affectioD is also comnaonly produced by cold, but is of littlfi 
importance, excepting when it results in the secretion of large qoan- 
titles of epidermis. A simple tumefaction of the dermoid layer 
usually affects the hearing power too slightly to cause the patient to 
apply for relief: in many instances where the layer has been hyper- 
trophied, the patients have suffered no inconvenience. If, however, 
it becomes so tumefied as to render the membrana tympani tense, 
then a perceptible deafness is induced. In the majority of eases of 
hypertrophy of the dermoid membrane, there coexists a thickening 
of the mucous membrane of the tj-mpanum, which causes the deaf- 
ness. The presence of several layers of epidermis on the outside 
of the dermis, is also a source of considerable deafness, and very 
frequently of uncomfortable sensations in the ear and head. 

Case I. Simple cliTonie inflammation of the dermoid lat/er, with 
an accumulation of epidermis on its surface, — Colonel T., aged 45, 
strong, and in good health, consulted me on July Ist, 1855, on ac- 
count of a buzzing Kensation in both ears, especially in the right, 
which had lasted for three months, accompanied by a feeling of op- 
pression iu the head and dulness of bearing. On examination, the 
watch was heard only when in contnct with the ear, and a large 
quantity of epidermis was observed at the bottom of the meatus. 
By means of the syringe, aeversil layers were extracted, and the 
surface of the dermis, which was red and thick, exposed. On the 
removal of the epidermis, the noises and unpleasant sensation in the 
head vanished, and the heaving was much improved; the hearing dis- 
tance with the watch being six inches. 

Case II. Cltrovic inflammation and hypertrophy of tlie demutd 
layer. — E. J., Esq., aged 25, visited me on March 29, 1853, on ac- 
count of dulness of hearing. 

History. — Five years ago, after a large portion of cerumen had 
been scooped out, had irritation in the ears, and remained deaf for 
some time afterwards. Three months ago, when suffering from deaf- 



THE MEMBRANA TTMrANI. 

ness, was relieved by the use of the syringe ; lately the left ear ban 
again become dull, and he has complained of pain in it, and in the 
left aide of the face. On examination, the right ear heard the 
watch at a distance of two inches; the left at the distance of an 
inch. The dermoid layer of each ntembraua tympani was hypertro- 
phied, and that of the left car was very red. 

Treatment. — A slight discharge was kept up from the surface of 
each mastoid process, and a weak solution of nitrate of silver (gr. v. 
ad. 3j) was applied to the surface of the affected membrane. 

April 9- — Hearing improved. The watch is heard by the right 
ear at a distance of three inches ; by the left, at a distance of seven 
inches. 



(c.) CBBOMIC CATARRHAL INFLAUMATIO:^ OF TUB DERMOID LAYER. 



This form of inflammation is far from being rare. Like the same 
disease of the dermoid layer of the meatus, it often occurs in chil- 
dren out of health, and also results from the application of cold to 
the surface of the membrane. It very frequently takes its origin 
in an attack of acute inflammation, which, instead of subsiding, be- 
comes chronic. The discharge usually consists of the epidermoid 
cells, which are thrown off in conjunction with a quantity of fluid, 
instead of forming a distinct epidermoid layer. On removal of the 
discharge, the dermis is found to be swollen, and entirely denuded 



of epidermis ; the color of the surface varying 



from ! 



deep to a 



palish red. The cases of this disease require the deepest attention, 
since they are apt to terminate in the formation of granulations or 
of polypi on the surface of the membrane, or in ulceration ; the 
latter process endangering the fibrous laminfe. This affection is 
also not unfrequcntly associated with a corresponding one of the 
dermoid layer of the meatus ; which may be subdued without the 
disease of the membrana tympani being cured. 

Caae I. Chronic catarrhal inflammation of the dermoid layer, loith 
ikiekening of the mucous membrane of the tympanum. — Rev. W. A., 
aet. 32, visited me on the 18th of November, 1854. 

Jliitory. — Since childhood the left ear has been useless. During 
the past year the right ear has beon dull of hearing at times, and 
he has complained of irritation of the ear, for which he has been in 
the habit of using an earpick. Lately his deafness has so increased, 



170 THE DISEASES OP THE EAR. 

that he has to be loudly spoken to within a yard of the head, and 
also complains of a discharge from the right ear. On examination^ 
the dermis of the meatus in the right ear was observed to be red, 
while the dermoid layer of the membrana tympani was partly red 
and partly white : there was also an abundant discharge of mucus. 

Treatment — The ear to be syringed out with warm water thrice 
daily, three leeches to be applied to the orifice of the meatus, and 
vesicating paper to be kept behind the ear. 

Nov. 26. — Much better : thinks he now hears as well as he has 
done for some years. The dermoid layer of the membrana tympani 
is less red ; the discharge is less abundant. 

Case II. Catarrhal inflammation of the dermoid layer after bath- 
ing, — Miss J. G., ajt 27, consulted me on September 15, 1855, on 
account of a dulness of hearing in the left ear, with discharge. 

History, — A year previously, immediately after bathing in the 
sea, felt a slight pain in the left ear, which continued for three or 
four days, and was followed by a discharge, which has remained 
until now, accompanied by a dulness of hearing. On examination^ 
the surface of the dermoid layer of the membrana tympani was found 
to be covered with discharge, which being removed, the membrane 
was seen to be red, and its bloodvessels distended. Under the 
same treatment as in the last case, the patient was cured in two 
months. 

Case III. Catarrhal inflammation of the dermoid layer after 
measles. Polypoid growth from the surface, — Miss M. E. S., aged 
10, not strong, was brought to me on April 2, 1853. 

History, — Three years previously had an attack of measles, fol- 
lowed by discharge from the left ear, and considerable dulness of 
hearing in both. Eight months ago had an attack of low fever, 
which remained for two or three months, and much increased the 
deafness. At the present time has to be spoken to distinctly within 
a yard of the right ear. Every night there is discharge, and a cer- 
tain amount of earache. Is better in warm weather. 

On examination^ there was found in the right ear a large quantity 
of discharge, which being removed, the dermoid layer was observed 
to be much hypertrophied, and red growths covered considerable 
portions of it, especially posteriorly. Hearing distance four inches. 

Left ear, — Membrana tympani white at the upper part, and the 
dermis much thickened: discharge abundant ; hearing distance half 
an inch. 



BRASA TYMPANI. 



Treatment. — A solution of chloride of zinc, two grains to the 
ounce, was injected into each ear daily, and a discharge was kept 
up from the surface of the mastoid process. Under this treatment 




the discharge disappeared, and the power of hearing was greatly 
improved. 

Case IV. Catarrhal inflammation of the dermoid lager, following 
vteagles. — Master M. N., aged 6, pale, thin, and of a scrofulous dia- 
thesis, was brought to me on the 12th of May, 1851, on account of 
a discharge from the right ear. 

Siitory- — Since infancy has been subject to attacks of earache : 
five months ago had an attack of measles, followed by a discharge 
from the right ear, which, though diminishing at times, haa never 
wholly ceased. No dnlness of hearing has been perceived. 

On examination, the hearing distance of the right ear was found 
to be reduced to four inches ; the meatus contained a large quantity 
of offensive discharge ; the outer surface of the membrana tympani 
was flat : the dermis was white, and much thickened. 

Treatment. — Tonic medicines were administered ; the ear syringed 
out with half n pint of tepid water thrice daily, and afterwards with 
a solution of tannin, three grains to the ounce ; and a stimulating 
liniment was rubbed over the mastoid process twice daily. This 



172 THE DISEASES OF THE EAR. 

treatment, persevered in for two months, removed the dlschargCi 
diminished the hypertrophy of the membrane, and improved the 
power of hearing. The patient was brought to me three or four 
times subsequently, suffering from a recurrence of the attack, but it 
always yielded to similar treatment. 



(d.) ULCERATION OP THE DERMOID LAYER OP THE MEMBRANA 

TYMPANI. 

Ulceration of the dermoid layer is an affection only occasionally 
met with, and is either the result of long-continued catarrh of the 
dermis, or of the application to its surface of irritating matters, or of 
cerumen. The symptoms are very similar to those described in the 
previous section ; there is, however, frequently a discharge of blood, 
and the pain is more severe. 

Case I. Ulceration of the dermoid layer from the presence of ceru- 
men. — Mrs. G., aged 40, saw me on Mjiy 26th, 1855. 

History. — Fourteen days previously she had a singing in the left 
ear, which came on suddenly after fatigue, and has remained until 
the present period ; it is accompanied at times with confusion in 
the head. 

On examination, the meatus was found to be full of cerumen, and 
the watch was only heard when in contact with the ear. On remov- 
ing the cerumen by a syringe and warm water, the outer surface of 
the membra na tympani was observed to be red. At its anterior 
part there was a small surface, about three-quarters of a line in dia- 
meter, where the dermis had been wholly destroyed by ulceration ; 
and there was also a small depression, at the bottom of which the 
membrane was red. Hearing distance reduced to eight inches. No 
applications were made, and the ulcer healed in a few days. 

Case II. Ulceration of the dermoid layer ; fibrous layers exposed. 
— J. A., Esq., aged 35, was sent to me on March 26, 1850, by Mr. 
Mossop, of Whitehaven. 

History. — Twenty years ago, had a polypus in the right ear, which 
was removed ; but it grew again, and was a second time removed ; 
since the last removal has had discharge at times from this car. 
Three years previously had a severe cold, was very deaf for a week, 
and then gradually recovered ; but since that attack has been very 



THE MEMBRAyA TYMPAKI. 



173 



deaf during a cold. Is at present suffering from a cold, and is so 
deaf as to require to be loudly spoken to close to him. 

Right ear. — On examination, the surface appeared to be red, and 
at the posterior part there waa a small depression, from which the 
dermoid layer had been eroded by ulceration. When the tympanic 
cavity is distended, there ia an outward bulging of the fibrous layers 
through the orifice in the dermis. Watch heard when in contact 
with the ear, 

Lfft ear. — The dermoid membrane is white and thick, and dis- 
charge issues from its surface. Hearing distance half an inch. 

Treatment. — A discharge waa kept up over each mastoid process, 
and small doses of blue pill wore admistered ; by degrees the hear- 
ing alightly improved. 

Case III. Ulceration of the dermoid layer. Discharge of blood. — 
M. S. Chambers, aged 7, waa admitted under m-s care at the St. 
George's and St. James's Dispensary, on January 18, 1850. 

Histortj. — A year and a half ago, suffered from an attack of small- 
pox, from which she waa very ill for six weeks. A few months after 
the attack, discharge suddenly issued from both ears, and has con- 
tinue<l ever since, being very offensive, and at times mixed with 
blood ; has lately been also Hubject to itehing in the cars, earache, 
pains in the forehead, and giddiness. On examining the right ear, 
its surface was observed to be red and tumefied, and there wa« an 
orifice, at the anterior part, through the whole of the laminae. 

Left ear. — The dermis is of a deep red, and its central portion has 
been destroyed by ulceration : when the tympanic cavity is distended 
with air, the fibrous layers bulge outwards. 

The treatment consisted in the administration of tonics ; in keep- 
ing up a discharge from the surface of the mastoid process ; and in 
the use of gentle astringents. After several weeks the discharge 
gradually diminished, and all pain ceaaed. 

3. The fibrous lamince. — Although the two fibrous laminffi are so 
distinct in their structure and relations, their diseases are so similar, 
and they are usually ao equally affected, that it is desirable to con- 
sider them together. The diseases to which they are liable are : — 
Acute inflammation, chronic inflammation, hypertrophy, ulceration, 
and calcareous degeneration. 



(»tarrbal iDflammation uf the dermoid laver ; but Hometinios it is 
the result of primary acute iuflammatioQ of tlie fibrous laycre. It 
tiBual I y occurs in persons of debilitated health, and is ofteu attended 
with considerable constitutional irritation. When it origiiiateB in 
catarrh of the dermoid layer, that membrane becomes destroyed in 
parts, and the outer surface of the radiate fibrous lamina is exposed 
to view. If in this state the mcmbrana tympani be examined willi a 
speculum and a strong light, the radiate fibrous layer is seen to 
form the floor of a depression, the margins of which are formed by 
the dermoid layer. In some cases this surface is covered by deep 
red granulationtj ; in others, large portions of the fibrous luminsc 
arc exposed, which pour out an abundant discharge without the 
presence of any granulations. After some of the fibres of the 




Tbs Msmbnaa Tympani Tulli 




Pronioiilotj. frum wenloiMi 



fibrous laminre are destroyed by the ulcerative process, the remain- 
ing fibres are so much weakened that the whole lamina falls inwards 
towards the surface of the promontory, and thus the size of the 
tympanic cavity is greatly diminished. In other instances, a great 
portion of the fibrous lamina is entirely destroyed, and the mucous 
layer alone remains ; or portions of all the lamime are eroded, and a 
perforation is the result. Upon inspection, a case of perforation of 
the mcmbrana tympani, produced by ulceration of the fibrous Inmina-, 
and advancing from without inwards, can always be distinguished 
from a case of perforation originating, as it more commonly docs, in 
catarrh of the mucous membrane of the tympanum, and advancing 



174 THE DISEASES OF THE EAR. 



(a.) ACUTE INFLAMMATION OF THE FIBROUS LAMINJB. 

When the fibrous layers of the membrana tjmpani are the seat 
of acute inflammation, the mucous membrane of the tympanum is 
usually similarly affected, which renders it diflScult to define the 
symptoms of acute inflammation of the fibrous layers. This affec- 
tion is usually excited by cold air striking the outer surface of the 
membrane ; hence, the suddenly passing from a heated room into 
cold air, especially in an easterly wind, often produces it. As in 
inflammation of the mucous membrane of the tympanum, there is 
commonly the predisposing cause of debilitated health. The symp- 
toms of this affection are a tickling sensation deep in the ear, often 
accompanied by involuntary movements of the membrana tympani, 
consequent on the irregular action of the tensor tympani muscle. 
This sensation increases, and a severe lancinating pain ensues, 
which is increased by the act of deglutition, the use of the hand- 
kerchief, coughing, or sneezing. On examination^ the surface of 
the membrane is seen to be shiny, its color more leaden than usual, 
tinged frequently with a reddish hue, from the distention of its 
vessels with blood. The affection commonly ends in resolution, but 
sometimes ulceration ensues, which will be afterwards described. 

The treatment of this form of acute inflammation consists in the 
use of leeches to the margin of the orifice of the meatus, followed 
by hot fomentations and poultices ; while calomel and opium are 
administered internally. Cases of this disease will be given under 
" acute inflammation of the mucous membrane of the tympanum." 



(6.) CHRONIC INFLAMMATION AND HYPERTROPHY OF THE 

FIBROUS LAYERS. 

In this affection, the fibrous layers continue for some time con- 
gested or become opaque. This disease will be treated of at length 
under the head of *' rigidity of the membrana tympani." 



{c.) ULCERATION OF THE FIBROUS LAMINA OF THE 

MEMBRANA TYMPANI. 

This affection commonly originates either in acute or chronic 



THE MEMliRA 



175 



catarrhal inflnminatioii of the dermoid layer ; but sometimes it is 
the result of primary acute inflauiination of the fihrous layers. It 
usually occurs in persons of debilitateil healtli, and is often attended 
with considerable constitutional irritation. When it originates in 
catarrh of the dermoid layer, that membrane becomes destroyed in 
parts, and the outer surface of the radiate fibrous lamina is exposed 
to view. If in this state the mcmbrana tynipani be examined with a 
speculum and a strong light, the radiate fibrous layer is seen to 
form the floor of a depression, the margins of which are formed by 
the dermoid layer. In some cases this surface is covered by deep 
red granulations ; in others, large portions of the fibrous laminae 
are exposed, which pour out an abundant discharge without the 
presence of any grfinulations. After some of the fibres of the 



Tba Metnbraaai TympBc 




sakneas or Lbs flbiaBi 



fibrous lamina arc destroyed by tlie ulcerative process, the remain- 
ing fibres are so much weakened that the whole lamina falls inwards 
towards the surface of the promontory, and thus the size of the 
tympanic cavity is greatly diminished. In other instances, a great 
portion of the fibrous lamina is entirely destroyed, and the mucous 
layer alone remains ; or portions of all the laminie are eroded, and a 
perforation is the result. Upon inspection, a case of perforation of 
the membrana tympani, produced by ulceration of the fibrous laminte, 
and advancing from without inwards, can always be distinguished 
from a case of perforation originating, as it more commonly does, in 
catarrh of the mucous membrane of the tympanum, and advancing 



176 



OF THE EAR. 



from within outwards. In tlie htttor class of cases, the i 

the orifice is sharp, smooth, and well defined ; its shape is usually 

round or oval ; and the remaining portion of the membrane, retain- j 




ing its natural plane, is smooth : whereas, in cases of perforation I 
from ulceration of the dermoid and fibrous layers, the margins and | 
form of the orifice are irregular ; and the plane of the remnant of | 




An OriSniD the Mrmbrank Tjmpanl prodoced b; alccration of the Bbroiu Ift 



the membrane, deviating from the natural state, is often funnel-' 
«1, and very concave externally. 
Ulceration of the fibrous layers of the niembrana tympani once | 
establiahed is liable to remain during many years, and is one of the ' 
diseases hitherto comprised under the term " otorrhtea." Some- 
times a large part of the substance of the fibrous layers la entirely 
effaced, and the outer surface of the mucous membrane pours out a . 
secretion. A singular accompaniment of this affection of the fibrous j 
laminie is a contraction of the carotid canal. I have so frequently I 




THE MEMBRANA 



177 



I 



fonnd tliia condition where tLc membrana tympani has been ulce- 
rated, and so rarclj met with it under otlier circumstances, tliat I 
am induced to consider it as connected with the ulceration. The 
treatment to be pursued in cases of ulceration of the fibrous laminsie, 
consists in washing out the meatus frequently with warm water, and 
in applying, by means of a syringe, a weak solution of tbe nitrate 
of silver, or some other astringent, to the part affected. If the 
membrana tympani has been perforated, the use of an artificial 
membrana tympani will often be of aervico. A slight discharge 
should also be kept up from the surface of the mastoid procesa, 
Concurrent ly with these local applications, measures should be taken 
to strengthen the general health. 

Case I. Ulceration of thefibroua lamtnce of the membrana tym- 
pani. — W. W., aged 50, a medical man, residing in London, con- 
sulted mc, in 1852, on account of a long-standing discharge from 
the left ear, accompanieil by deafness. 

HiMory. — In early life, after repeated attacks of earache, a dis- 
charge flowed from the left ear, which has not ceased for more than 



b 




The Pifamut Lajera 
part. The tDQcou 
Th<> iUxulrotiuD, 



if the Membrann Tynipnni uloernlsd i.ver a 
uambrttiB, reiiuiitiiog, furma a mimll c 
om a prcparalion in mj niugeam, giv«8 an 



I 



a week or two at a time since that period. Lately there 1ms been 
at times great deafness, producing extreme inconvenience, as the 
right ear has been useless during many years. L^pon sjT-inging the 
left ear, a large quantity of o9"en8ive matter was removed, and the 
membrana tympani became distinctly visible. Its circumference 
was in a natural state, but at the central part the dermoid and 
fibrous layers had been destroyed by ulceration, so as to disclose 
the outer surface of the mucous layer. Instead of forming a sep- 
tum in the situation of the natural organ, the membrane was nearly 
12 



178 THE DISEASES OF THE EAR. 

in contact with the outer surface of the promontory. Upon the 
patient swallowing with closed nostrils, the mucous membrane was 
observed to bulge outwards, and form a kind of bubble, which re- 
mained until the act of swallowing was repeated with the nose open, 
when the membrane again fell inwards. During the time the mem- 
bran0 projected outwards, the hearing power was greatly improved ; 
but diminished as soon as it fell inwards. 

The treatment consisted in syringing out the ear twice daily, bo 
as to remove the discharge, in applying a weak solution of nitrate 
of silver to the outer surface of the membrane, and in keeping up a 
slight counter-irritation over the mastoid process. The result was, 
that the power of hearing improved, and the condition of the mucous 
membrane became so much strengthened that, instead of falling in- 
wards towards the promontory, it was able to form a tympanic cavity. 
So long as that remained, the hearing was excellent ; but if from 
any cause the mucous membrane fell inwards, the performance of 
the act of deglutition, during the closure of the nostrils, immediately 
restored it to it« natural position, and improved the hearing. - 

Case II. llceration of the fibrous lamince of the membrana tym-- 
pani, — Mrs. E. C, aged 38, consulted me in June, 1850, on account 
of deafness in both ears, accompanied by giddiness and discharge. 

History, — Twenty years previously she had a bad cold, followed 
by deafness and a discharge from both ears ; and the latter has con- 
tinued to the present time. Has been subject to attacks of earache, 
usually followed by an increase of the discharge, which, during a 
cold, is much more abundant, often becoming very offensive. During 
the last year has been much worse, complaining of much singing in 
the head, and giddiness. She requires to be distinctly spoken to 
within the distance of a yard. On examination^ a quantity of fluid 
discharge having been removed from each meatus, the right mem- 
brana tympani at the posterior and lower part appeared white and 
thick, while the anterior and upper part had fallen inwards, and 
appeared as if attached to the promontory ; its outer surface was 
uneven, and poured out the discharge; air passed through the Eusta- 
chian tube. Hearing distance two inches. 

Left ear, — Hearing distance one inch. The upper half of the 
membrana tympani had fallen inwards, was red, and poured out a 
discharge. The treatment consisted in keeping up a discharge from 
the back of the neck, in syringing out the ears twice daily, and in 
applying a solution of nitrate of silver (gr. xx ad gj) to the surface 



179 



of tte membrane. This treatment was pursued during two ntontlia: 
the discharge gradually diHappcarcd ; and the hearing was greatly 
improved. 



{d.) CiLCABEOCS DEGENEIUTION OF THE FIBKOITS LAiUtlJE 
OF THE MBMBRANA TYMPANl. 

The fibrous laminse of the merabrana tympani frequently undergo 
calcareous degeneration. This change occurs at all periods of life ; 
sometimes taking place when the remaining portion of tlio membrane 




is healthy, and no other abnormal state can he detected in the organ. 
In some caseH this calcareous condition of the membrane is symp- 



OalMreon* Depoait is tha Radiats Flbroui 




if lb< Mnnbraa* Tjinpuii, 



tomatic of calcareous deposit within the tympanic cavity ; in others, 
it follows, and appears to be produced by, chronic inflammation, 
with or without catarrh of the dermoid layer. After ulceration and 
destruction of portions of the membrane, the residue is also at times 
converted into calcareous matter. Sometimes the calcareous matter 
is arranged in a circular form, when it will be found to be deposited 
in the circular fibrous layer ; at other times it assumes a radiate 



180 



THE DISEASES OF THE BAK. 



form, and then the radiate fibrous layer is the seat of the deposit; 
In other cases the whole mass of the membrane Is converted inU 
calcareous matter. Where there is much diminution of the powei 




Tha whole of tha Membniu Tjmpani 



of heurlng in this disease, there is usually partial or complete ancli^- 
losia of the stapes to the feneetra ovalts, and any treatment moat 
have for its object the diminution of the anchylosis. Patients ap- 
plying for relief in such cases must therefore be treated hycounter- 
irritatioQ over the mastoid process, &nd by the admiDJstratlon of 
alteratives. 

Cage I.— M. C, aged 82, consulted me in December, 1854. 

Hwtory. — When a child he had an attack of measles, followed by 
great diminution of the power of hearing, so that he has ever si 
been unable to hear unless the speaker's voice is raised higher tban 
natural, and brought near to him. There has been discharge for 
many years from the right ear. On examination, the meatus of that 
ear was fouuil full of thick discharge ; when this was removed by 
the syringe, the upper half of the membrana tympani was seen to 
be calcareous, the lower half transparent. The Eustachian tube waa 
pervious. W'atch not heard when in contact with the ear ; but the 
crack of the nail was heard at the distance of a foot. 

Left ear. — The anterior half of the membrana tympani was calca- 
reous ; Eustachian tube pervious ; hearing power the same as in the 
opposite ear. Gentle counter-irritation over the mastoid process was 
ordered. The patient was not seen a second time. 

Case U.—J. G. T., Esq., oged 18, consulted me in 1855. The 
general health was good, with no hereditary tendency to deafneea. 

Si»tory. — Five years previously dulness of hearing slowly ap- 
peared after an attack of influenza ; two years subsequently suffered 
from scarlet fever, followed by discharge from each ear, and by a 
great increase of deafness. The discharge has now ceased ; bat 



THE MEMBRANA TYMPANI. 



181 



tbere is so mucb deafness that lie has to be loudly spoken to wtttun 
three feet. At times, especially during a cold, earache is com- 
plained of. On examining the right ear, the watch was heard at 
the distance of half an inch. The greater part of the lower half of 
the membrana tympani was converted into a mass of crescent-shaped 
calcareous matter, but the other part of the membrane was healthy. 
Eustachian tube pervious. 

Left ear. — Watch heard on pressure over the ear and over the 
temple ; the membrana tympani is more concave than natural ; and 
there is a patch of calcareous matter, similar in shape and size to 
that of the right ear. Eustachian tube pervious. The same treat- 
ment waa pursued as in the last case, and with some benefit. 

Case III. — Mrs. B., aged 34, in good health, but subject to bilious 
attacks, consulted me in 1854. 

ffi'sfory.— Since an attack of earache when a cliild, the left ear 
has been useless. Three months ago the right ear became suddenly 
deaf after a cold ; the deafness was treated by syringing, the opera- 
tion being followed by alight bleeding, but no immediate improve- 
ment. After a few days, however, the hearing improved, but the 
ear was extremely sensitive, and there was a constant feeling of re- 
verberation in it. When more than one person spoke at a time, con- 
fusion in the ear was produced, and, during the act of swallowing, a 
grating sound occurred in the organ. Noise like that of a waterfall 
is constantly present on the right side. On examining the right' 
ear, the larger part of the membrana tympani was found calcareous ; 
the Eustachian tube was pervious ; the hearing distance was six 
inches. The membrana tympani of the left ear had so fallen in as 
to be in contact with the promontory. The watch was not heard, 
but the crack of the nail was heard at a distance of three inches. 
The treatment consisted in keeping up a slight discharge from the 
surface of the mastoid process, which was followed by great diminu- 
tion of the distressing noises in the ears. 



(e.) RELAXATION OP THB FIBROUS LAMINA OF TBB MEMBRANA 
lYMPANI. 



Some writers have doubted the existence of the disease called 
' relaxation of the membrana tympani." Thus Dr. Kramer' says : 



' Od tbe DiwBTCl of Ui« Eu 



.ted by Bennatt. p. 143. 



182 THE DISEASES OF THE EAR. 

'^ I may be allowed to banish relaxation and tension of the mem- 
brana tympani from the catalogue of diseases met with in practice, 
in which I have, indeed, been preceded by Itard, who, however, has 
not adduced his reasons." Although the writers who preceded Dr. 
Kramer, who had spoken of this disease, had not described the symp- 
toms nor the appearances by which it could be recognized, they were 
nevertheless correct in stating that the disease in question existed. 
Indeed, it appears to me that no disease of the ear can be more dis- 
tinctly diagnosed than the one under consideration. 

The causes of this disease are : — 1st, the effects of an ordinary 
cold, producing hypertrophy of the mucous layer ; 2d, inflammation 
of the fibrous layers. From either of these causes, the membrana 
tympani may lose its natural degree of resiliency and become flaccid 
so as to fall inwards, and approach more nearly to the promontory 
than is natural : a change which ends in great dulness of hearing. 
This dulness may, however, be temporarily relieved by pressing out 
the drum to its natural position, either by swallowing with closed 
nostrils, by attempting a forcible expiration, or by forcibly and 
rapidly inhaling air through tlie nose. No sooner, however, is the 
act of swallowing in the natural way repeated, than the air escapes 
from the tympanic cavity, the membrana tympani falls inwards, and 
the dulness immediately returns. The treatment depends in a mea- 
sure upon the cause of the affection. If the mucous membrane 
lining the tympanum be thickened, counter-irritation over the mas- 
toid process should be practised ; if the fibrous laminse are inflamed, 
leeches should be applied to the margin of the meatus. Where the 
fibrous laminie are weakened, a solution of the nitrate of silver ap- 
plied to the outer surface of the membrane is frequently of great 
service. There are cases where the deafness is not in the least de- 
gree relieved by forcing air into the tympanic cavity : when this 
happens, it is most probable that partial anchylosis of the stapes 
has taken place. The following cases illustrate fully the symptoms 
and treatment of this disease. 

Case I. Mvmhrana tympani relaxed ; deafness temporarilj/ di- 
minished after filling the tympanic cavities with air. — S. B., Esq., 
aged 18, consulted me in November, 1853, on account of dulness of 
hearing. 

History. — Several years previously, he became dull of hearing, 



THE MEMBRANA TVMPA 



without pain or any assignable cause, am! lately tlie affection lias so 
much increaaed, that he requires to be loudly spoken to within the 
distance of a yard. The deafness is greatly aggravated during a 
cold. The power of hearing is much improved whenever be baa 
blown air into each tympanic cavity ; but as soon as the act of de- 
glutition is naturally performed, a aensation of weight ia felt in the 
ears, and the deafness returns. On examination of the right ear, 
the membrana tympani was found to be opaque ; its bright spot 
elongated; the form more concave externally than is natural. On 
swallowing, or forcing the air with the nose closed, the membrana 
tympani expands to its natural form, and remains so until the act of 
deglutition is repeated with the nose open, when it again falls in- 
wards. Hearing distance with watch, half an inch. The left is in 
the same state as the right ear. The mucous membrane of the 
fauces is red and thick. 

Treatment. — As there was an evident thickening of the membrana 
tympani, vesicating paper was applied behind each ear ; the sixteenth 
of a grain of bichloride of mercury was administered every night ; 
and a lotion was applied to the outer surface of each membrana 
tympani, consisting of three grains of nitrate of silver to an ounce 
of distilled water. This treatment, at the end of a fortnight, so 
greatly improved the patient's power of hearing, that he could dis- 
tinctly hear an ordinary voice at three yards' distance. This 
improvement continued until the patient took a severe cold, when 
the deafness recurred ; but was subdued again by a repetition of the 
treatment. 

Case II. Membrana tympani relaxed and eongcited ; symptoms 
diminished temporarily by a forcible inspiration through the nose. — 
J. J., Esq., aged 35, came to consult me in September, 1853. 

HiaUrrg. — Since a child, has been subject to earache in each car. 
For a year or two, this pain has occurred in the right ear only, and 
has lately been very considerable. Complains of a feeling of rum- 
bling in the cars, and of so great a dulncss of hearing that he has to 
be spoken to distinctly within the distance of a yard. The rumbling 
sensation and the deafness are both temporarily relieved by suddenly 
and forcibly drawing in the breath through the nostrils ; but this im- 
provement disappears immediately the act of swallowing is naturally 
performed, and if that act is delayed, the symptoms slowly return in 
in the course of a few minutes. The patient has thus acquired the 



184 



THE DISEASES OF THE EAR. 



habit of inceasantly " sniffing" the air, whicli is exceedingly nnple»« 
sant to himself ;in(l to every one around him. While sitting in my 
room, he must Lave performed this act twenty or thirty times. On 
examination, each membrana tympaiii whs found red and dull, with 
the bright spot much larger than natural. 

Treatment. — As there was palpable congestion of the raembrana 
tympani, leeches were applied to the margin of the meatus ; a veai- 
eating paper kept on each mastoid process ; and a warm solution of 
chloride of zinc (gr, ij @ Jj) was droppe<l into each meatus twice 
daily. By persevering in this plan of treatment for three months, 
the patient could hear nearly as well as was natural, and had com- 
pletely lost the habit of " sniffing." 

Case III. Relaxation of membrana tympani from thickening of tin 
ti/mpanie mucous membrane, produced by a cold; deafness improved 
by forcing air into the ti/mpanum, and by syringing with water. — • 
Miss J., aged 50, applied to me in May, 1853. 

History. — Suffered when a, child from disease of the left ear, which 
produced total deafness. For some years the left ear has been doll 
daring a cold, and at times the deafness is very great ; at present 
the patient has to be spoken to loudly within the distance of two 
yards ; but after forcing air into the tympanum, the hearing is tem- 
porarily so improved that she can hear what is said in any part of 
an ordinary sized room. This improvement can also be produced 
by syringing water ; but under either treatment, the dulness of hear- 
ing speedily returns. In order to keep up a tolerable amount of hear- 
ing, she has fallen into the babit of blowing air into the car every 
few minutes. On examination of the right ear, the hearing distance 
was found to be two inches. The membrana tympani was wlutc, the 
surface shiny. Air entered through the Eustachian tube, and when 
it distended the tympanic cavity, the membrana tympani was seen 
to move outwards to a much greater extent than natural. This 
movement was followed by a great improvement in the hearing, 
which, however, very soon disappeared. 

Treatment. — Considering this to be a case of relaxation of the 
membrana tympani, produced by thickening of the tympanic mucooB 
membrane, slight counter-irritation was excited over each mastoid 
process, and a solution of nitrate of silver (gr. iij @ §j) was dropped 
into each ear every night. Tonics were adminiBtered. After this 
treatment had been pursued for a fortnight, a manifest improvem^it 



THE MEMBRANA TYMPANI. 185 

took place, the patient heard better, and had no occasion to force 
air into the ear ; the habit, too, has been nearly overcome. I have 
seen this patient once or twice since,— once during the year 1855, — 
and the result of the treatment has, on the whole, been satisfactory ; 
the hearing remained much better, except during attacks of cold, 
when the old habit of " clearing the ears," by forcing air into them, 
was had recourse to. 



CHAPTEK X. 

THE MEMBRANA TYMPANI (concluded). 

PERFORATION, CAUSES — PHYSIOLOGICAL OBSERVATIONS — EXPERIMENTS PBKY10U8 TO 
THE FORMATION OF AN ARTIFICIAL MEMBRANA TYMPANI — ON THE ARTiriCIAZ. MBK- 
BRANA TYMPANI — THE MODE OP APPLYING IT — CASES — RUPTURE OF THE KBlCBBAjrA 
TYMPANI — PHYSIOLOGICAL OBSERVATIONS — PATHOLOGICAL 0BBEBYATI0H8 CASKS. 

(a) PERFORATION OF THE MEMBRANA TYMPANI, AND THB USB 

OF THB ARTIFICIAL MEMBRANE. 

When speaking of ulceration of the fibrous layers of the mem- 
brana tympani, I had occasion to point out that perforation of the 
membrane itself sometimes, though rarely, takes place as a result. 
The usual cause of perforation of the membrana tympani is catarrh 
of the tympanic mucous membrane. In the latter case, a large 
quantity of mucous is excreted, which fills the tympanic cavity, and 
being too viscid or too abundant to escape through the Eustachian 
tube into the fauces, it consequently presses against the inner sur- 
face of the membrana tympani, causing gradual absorption of its 
substance, and ultimately perforation. That this aflFection is not 
the result of primary ulceration of the mucous membrane lining the 
inner part of the membrana tympani, is shoAvn, I think, by the fact 
that in cases of perforation no appearances of ulceration are obser- 
vable in any other parts of the tympanic cavity ; indeed, as will be 
seen, when considering the diseases of the mucous membrane of the 
tympanum, ulceration is comparatively a rare occurrence. 

The most usual cause of perforation of the membrana tympani is 
scarlet fever : in other cases it is connected with scrofulous disease, 
the mucous membrane of the tympanum throwing out large quan- 
tities of mucus. The result of a perforation of the membrana tym- 
pani, as all medical men are aware, is a certain diminution of the 
hearing power. A small orifice, unattended with any other lesion 



THE MEM BRAN A TYMPANI. 



187 



of the organ, does not produce bucIi a degree of deafness as to be 
very uncomfortable ; but, if in addition to the small orifice, there is 
a thickened and relaxed condition of the mucous membrane of the 
'tympanum, or of the remaining portion of tlio raembrana tympani, 
then very serious diminntion of the hearing power occurs. Even a 
large ori6ce in the membrana tympani often docs not produce any 
serious amount of deafness ; bnt if it is accompanied with much 
thickening of the mucous membrane of the tympanum, the patient is 
entirely debarred from conversation, except when specially addressed, 
in a loud tone, within the distance of a yard. What is the cause of 
deafness in cases of perforation ? There is, it seems to me, no doubt 
but that one of the functions of the membrana tympani is to con- 
fine the sonorous undulations to the tympanic cavity, hi order that 
they may be concentrated on the membrana fenestrse rotundse. In- 
deed, it is probable that the vibrations only partially pass through 
the chain of hones to the vestibule, and that the air in the tympanic 
cavity is one great medium of communication with the labyrinth. 
If the means of communication with the labyrinth be the air in the 
tympanic cavity, it is palpable that an aperture in the membrana 
tympani is likely to diminish the power of hearing, by permitting 
the ribrations to escape from that cavity into the meatus, and so 
prevent their concentration upon the membrana fenestroe rotundie. 
This explanation of the diminished power of bearing in cases of 
perforate membrana tympani, seems confirmed by the result of the 
treatment adopted for their amelioration. 

Treatment. — Until very recently, the deafness arising from the 
presence of an aperture in the membrana tympani was regarded as 
incurable, and no systematic treatment was attempted, although 
several writers had alluded to the beneficial consequences following 
the introduction of foreign bodies, especially of lint and cotton-wool, 
where there was perforate membrana tympani. Thus Itard cites a 
case in which the deafness was completely relieved by introducing a 
portion of cotton-wool to the bottom of the meatus. Deleau, too, 
speaks of a patient who greatly improved his hearing, using in this 
way a piece of wool or the central part of an onion. Mr. Todd de- 
scribes " the relief derived from the mere introduction uf a little lint 
into the external meatus in those cases where the membrana tym- 
pani has been ruptured or destroyed by disease. So great, indeed, 
is the improvement which takes place from the application of this 
simple remedy, that patients will frequently appear astonished at 



THE DISEA 



being 80 easily relieved."' In the year 1848, Mr. Yearaley pub- 
lished a pamphlet entitled, "On a New Mode of Treating Deafness 
when attended by partial or entire Loss of the Membrana Tytnpani, 
associated or not with Discharge from the Ear." In this pamphlet' 
he advocates the application of cotton-wool in a moistened state, in 
cases of partial or entire loss of the membrana tympani ; tho object 
of this snbatance being, as be has subsequently slated, " to support 
the remaining portion of the membrana tympani, or the ossicula."' 
Respecting the mode of applying tho wool, the following are his in- 
structions : " A Bmall piece of wool, differing in size according to 
the case, and fully moistened in water, is introduced through the 
speculum to the bottom of the meatus, and adjusted superiorly, infe- 
riorly, anteriorly, or posteriorly, according to the situation of the 
perforation and other circumstances connected with the case ; but 
care must he taken that the entire opening be not covered, otherwise 
the experiment will not succeed. It is also indispensable to success 
that the moisture of the wool should be preserved." 

After having conducted some researches into the functions of the 
tympanic cavity, which were laid before the Royal Society, and 
made some experiments upon the cars of patients suffering from per- 
forate membrana tympani, it appeared to me that an artificial mem- 
brana tympani could be constructed which might confine the vibra- 
tions to the tympanic cavity, and concentrate them upon the laby- 
rinth. The course of investigation which has been pursued by tae 
showed that the guttural orifice of tho Eustachian tube is closed, 
except during the momentary action of certain muscles, and that 
for all purposes relating to the passage of sonorous undulations the 
tympanum is a shut cavity ; and next, that by a modification of Mr. 
Wheatstone's experiment with a tuning-fork, suggested to me by 
Mr. C Brooke, the sonorous vibrations communicated to the bones 
of the head appear much louder when the meatus extemns is closed 
than when the orifice is open. 

If, for instance, a tuning-fork he made to vibrate, and then be 
placed in contact with the head, the sound proceeding from it will, 
in a few seconds, cease to be beard ; but if directly on this cessation 
of sound, the experimenter close the entrance of the meatus in one 
ear so as to convert it into a shut cavity, he will instantly hear a 
renewal of the sound of the tuning-fork ; from which it appears 



THE MEMBRANA TYMPANI. 



189 



most probable that t!ic sonorous vibrations communicated to the ex- 
ternal meatus impressed the membrana tympani much more power- 
fully when confined within the meatus than when allowed free com- 
munication with the external air. Considering the result of this 
esperiment in connection with the other fact of the ordinarily closed 
state of the tympanic cavity, it appeared to me highly probable that 
the sonorous vibrations imparted to the cavity of the tympanum, 
could only make their due impression on the membranes of the laby- 
rinth when strictly confined to the tympanic cavity, and not allowed 
to expend themselves in the cavity of the fauces. This conclusion 
was strengthened by the fact, that all the walla of the tympanic 
cavity appear expressly constructed for producing resonance, having 
an investing membrane of so great tenuity as scarcely to be detected 
save by the touch or the use of a magnifying glass, and also by the 
observation, that this peculiar condition of the mucous membrane 
was restricted to the tympanic cavity itself and to that portion of 
the Eustachian tube which forma part of the resonant walla of that 
cavity. 

If the view here advanced be correct, and if for the perfect per- 
formance of the function of hearing it be necessary to confine the 
sonorous vibrations to the tympanic cavity, it is clear that the ana- 
logy usually cited as existing between the kettle-drum and the tym- 
panum of the human ear, to the effect that in both the air within 
should be allowed to communicate with that without, is incorrect ; 
and it is further evident, that an opening in the membrana tympani 
must more or less diminish the power of hearing. On examining 
patients affected with simple perforation of the membrana tympani, 
the impaired inability to hear can, in fact, alwaya be detected ; al- 
though, as has been stated, if the orifice be small and the organ 
Otherwise healthy, the difference is but slight. In the greater num- 
ber of cases, however, where perforation of the membrana tympani 
exists, other lesions of a serious character have coexisted, *ich as 
thickening of the membrane of the tympanum, pressure on the mem- 
brane of the fenestra rotunda, derangement of the articulation of 
the stapes with the fenestra ovalis, or injury to the nervous expan- 
sion in the labyrinth. Under any of these circumstances it occurred 
to me, that as an orifice in the membrana tympani, by preventing 
the sonorous undulations, owing to their diffusion in the meatus, 
from being concentrated upon the membranes of the labyrinth, 
might be a direct cause of diminution of hearing power, so it was 



190 THE DISEASES OF THE EAR. 

probable that increase of that power woukl follow an artificial closing 
of the orifice. 

The preceding train of investigation led me to attempt the con- 
struction of an artificial membrana tympani, which, it was hoped, 
might serve as a substitute for the natural membrane, so far, at 
least, as its function of closing the tympanum, and thus rendering 
its walls resonant, was concerned. 

These expectations of success were strengthened by the result of 
observations made by me on cases of perforate membrana tympani. 
Wlien such cases are not complicated with any serious lesion of the 
organ, it must have been remarked by others as well as by myself, 
that the patient, from some apparently inexplicable cause, at times 
suddenly hears perfectly well, or nearly so. This return of the 
hearing sometimes remains for a few minutes only, at others, for one 
or more hours. Having found the improvement to follow the use of 
a syringe and tepid water, or even of the handkerchief, I examined 
the ear in certain patients after these operations were finished, and 
found that in the former case a bubble of water, in the latter, of 
discharge, had filled up the orifice in the membrana tympani. On 
destroying the bubble, the improvement in the hearing at once dis- 
appeared. In one patient its stay could be prolonged by the use 
from time to time of a solution of gum acacia in water. On recon- 
sidering these facts, since the completion of my observations upon 
the closed state of the tympanic cavity, I have arrived at the con- 
viction that the bubble of water, discharge, or mucilage, acted bene- 
ficially by temporarily reconfining the sonorous undulations to the 
tympanum, a conviction which subsequent observations have 
strengthened. 

After some experiments, I tried vulcanized India-rubber and 
gutta-percha, making use of the thinnest layers of them that were 
procurable. With both these substances, I succeeded in making a 
rude kind of artificial membrana tympani, by cutting a portion 
about the size of the natural membrane, and passing through it a 
piece of thread, by means of which it could be conducted through a 
fine tube to its proper situation. The tube was then withdrawn, 
and the thread left in the meatus, so that the patient, or the ope- 
rator, could remove the artificial membrane at pleasure. The dis- 
advantages of this apparatus were — difficulty of applying it on the 
part of the patient ; liability of the material to be torn by the 
thread ; and the unsightliness of the latter hanging down from the 



MEM BR ANA TYMPANI. 



191 



meatus. The expcrimont, however, was bo far satiBfiictory ns to 
induce me to request Messrs. Weiss to construct one, the centre of 
which should consist of two very fine plates of silver, having a dia- 
meter of about three-quarters of a line hclween which the layer of 
Tuleanized india-rubber, or gutta-percha, might he placed, and 
having a silver wire attached to the surface of the outermost plate. 
The artificial membrana tympani, made by Messrs. Weis.s from 
these directions, has hitherto been perfectly successful. Ah sup- 
plietl by them, the portion of vulcanized india-rubber (the only ma- 
terial now used) is about three-quarters of an Inch in diameter, 
which leaves ample margin for the surgeon to cat out a membrane 
of any shape that may seem to him desirable ; and to leave the 
silver plate either in the centre or towards the circumference at his 
discretion. The silver wire is of sufficient length to admit of the 



®V- 



membrane being introduced or withdrawn by the patient, but is not 
perceivable externally, except by special observation. A pair of 




iferuDct of the Membrntiii Tpupnini remaiDing aftfr the datraclion ui 



forceps is made, by which the artificial membrane can bo more easily 
intrbduced or withdrawn. 



192 



DISEASES OF TUE EAR, 



Before describing the method of applying the artificial membra 
tympani, a few words are required respecting the state of the r 
maining portion of the membrana tympani, after perforation has I 
taken place. The orifice is, in some cases, not larger than a pin'iJ 
head; in others, a line in diameter; while in many, the eatiral 
membrane is destroyed, with the exception of a margin at the cip- 1 
cumference, about half a line in diameter, which being composed of 1 
the combined fibres of the thickest portion of the circular and radiate f 
laminie, generally remains. This margin is deepest at the upper j 
part. In rare cases, the long process of the malleus continues 
entire, after the complete destruction of the membrane to wbicli 
it was attached ; but, as a general rule, the whole of this pro- i 




cess is gradually absorbed, leaving merely the head of the bone I 
(which articulates with the incus), the neck, and the body, which J 
receives the attachment of the tensor tympani ligament internally. I" 
Anteriorly and posteriorly the fibres of the remnant of the mem- 1 
brane are attached ; and externally the processus brevis remains. 
It will, therefore, be understood, that in cases of so-called destmo- 1 
tion of the membrana tympani, a margin is generally left, to which J 
the body of the malleus remains fixed, and to the inner part of this 1 
the tensor tympani ligament and muscle are attached ; affording the J 
means by which the small bones and muscles of the tympanum are ] 
still enabled to perform their functions. In cases of general uloe- I 
ration of the mucous membrane of the tympanum, which fortunately J 
seldom occurs, the incus is commonly discharged, and sometimes tbel 
malleus also; but even in these cases, if the attachments of the J 
stapes to the circumference of the fenestra ovalis remain uninjured, I 
the power of hearing may be greatly improved ; should the stapes, J 
however, be removed, total and irremediable deafness ensues. - 



M B M B R A K A 



lfl3 



The artificial membrana tyinpani is of the gvealest benefit in those 
cases where there is a well-defined aperture in the natural inem- 
brane, or, if that membrane be entirely absent, where there is 




Badj or Mkllens remftlniDg oRer ileslructioD of Membnnn Tjmpanl. 



simple hypertrophy of the mucous membrane of the tympanum, 
with or without discharge from its surface. In these cases, the 
organ will be found to have by no means entirely lost its power of 
discerning sounds ; for, as a general rule, the human voice is heard 
when the speaker's mouth is brought within a foot of the patient's 
ear, and the speech is slow and distinct. This diminished power of 
hearing entirely excludes the sufl'orer from the advantages of gene- 
ral conversation ; but the deafness is greatly aggravated when to 
the affection of the membrana t^'mpani and mucous membrane of 
the tympanum is added anchylosis of the stapes to the fenestra 
ovalts, or when the nervous expansions have been injured. In sueh 
cases, the patients have to be shouted to close to the ear, and the 
artificial membrane is useless. 



Tea MODE OF APPLTIKG THE ARTIFICIAL MHMBEANA TYMPANI. 



As in cases of perforation or destruction of the membrana tym- 
pani, there is so frequently catarrhal inflammation of mucous mem- 
brane of the tympanum, it is obviously important that no foreign 
substance should be placed in contact with that membrane ; and as 
there is always a margin of the membrana t^'mpani remaining, the 
surgeon should be careful to keep the artificial membrane external 
to it. After accurately noting the aize of the inner extremity of 



194 



THE DISEASES OP THE EAR. 



the mentiis to which the natural membraDe was attached, th« ope- 
rator should proceed to cut the artificial membrane as nearly of the 
size and shape of the natural one ns possible, taking care at the 
same time to keep the margin quite smooth and regular.' The 
patient should then be placed with the head inclined to the opposite 
shoulder, while a strong light is thrown into the meatus, which, if 
liable to discharge, should have been previously syringed. The 
operator will next take the artificial membrane, and having moiat- 
ened it with warm water, pass it, by means of the silver wire, gentJy 
inwards until it has reached what he considers the natural position. 
This he will ascertain by the occurrence of a faint bubbling sound, 
caused by the escape of the slightly compressed air beyond it ; he 




TSB MEMBRA 



TYMPANI. 



195 



will complain of pain, which up till then hnd not been felt. The 
most certain test, however, of the proper placing of the artificial 
membrane, is the eensation of the patient, who discovers, by the 
sound of his own voice, or that of the surgeon, or by the movement 
of his tongue and lips, that his hearing has been suddenly improved. 
As wilt be imagined, great care must be taken to cut the mem- 
brane 80 that it shall fit the inner extremity of the meatus with ex- 
actness ; since if too large, it would cause discomfort, and if too 
small, it would not fulfil its purpose, of rendering the tympanum an 
air-tight cavity. It is not easy, in all cases, to fit the artificial mem- 
brane, 80 aa not to allow of any communication between the air in 
the tympanum, and that in the external meatus; this, however, is 
the object which should always be aimed at. The patient, at first, 
should be told not to use the artificial membrane for more than two 
hoars daily ; and if any uncomfortable feeling is experienced, one 
hour, or even half an hour, will be sufficient. 

It might, perhaps, be expected, that the contact of a foreign body, 
like the artificial membrana tympani, with the walls of the external 
meatus, would soon become intolerable; such, however, is not the 
case ; several patients have left my room without being able to say, 
from the sensation in the ear, whether any foreign body were there ; 
and many have now worn this apparatus daily, during several years, 
without suffering the least paiu. The explanation of this circum- 
stance may be found in the fact, that the most sensitive part of the 
meatus externus is about its centre, while the membrane in the im- 
mediate vicinity of the membrana tympani is less abundantly fur- 
nisheil with nerves : to this may be added, that the circumference of 
the artificial membrane presses with extreme gentleness against the 
wall of the meatus. 

The results of the application of the artificial membrane have been 
more satisfactory than theie was reason to anticipate. I have al- 
ready used it beneficially in many hundreds of cases. The substi- 
tution of a thin layer of vulcanized india-rubber for bo exquisitely 
delicate a structure as the healthy membrana tympani, would be 
expected to afford but trifling aid ; yet such is not the case ; for 
among the patients relieved by it, most have heard the human voice 
perfectly across an ordinary sized room, and in one case, the voices 
of boys in the open air, were heard at a distance of between one 
and two fields. Surgeons who have paid careful attention to dis- 
eases of the ear, will not be surprised at the efficient substitute the 



196 



THE DISEASES OP THE EAB. 



artificial membrane offers, as thej will call to mind inanj 
which the natural organ has been greatly hypertrophied, especially 
in chronic inflammation of its dermoid layer, ivith but a very slight 
diminution of the power of hearing. 

The surgeon having ascertained that the artificial membraDe U 
beneficial to the patient, it may be allowed to remain in the ear for 
a few hours, and the time gradually increased to a whole day. It 
is often desirable, that the use of the membrane should be preceded 
or accompanied by vesication over the mastoid process, whereby the 
thick mucous membrane of the tympanum may be rendered more 
healthy. In all cases, the artificial membrane should be removed at 
nigh;, and when there is any discharge, the ear should be syringed 
night and morning with tepid water. 

Oaie I. Deafnett for sixteen, years; ditcharge from each earfw 
nx t/ears; aperture in each membrana tympani; power of hearing 
restored. — Peter Turnbull, aged 43, formerly in the army, from 
which he was discharged on account of deafness, was admitted under 
my care, at St. Mary's Hospital, on the 12th January, 1852. He 
stated that sixteen years ago, without any other assignable cause 
than a cold, he became slowly dull of hearing, and five or six years 
ago, a discharge issued from both ears, which has continued to the 
present time. The power of hearing has been gradually declining, 
BO that at present he must be loudly addressed close to his head. 
On examination, an aperture, between one and two lines in diameter, 
was observed in each membrana tympani, and the mucous membrane 
of the tympanmn, which was the source of the discharge, was thicker 
and redder than natural. 

The treatment consisted in keeping up counter-irritation over each 
mastoid process, and in the use of an injection composed of three 
grains of acetate of zinc to an ounce of water ; and under this he 
somewhat improved, though tlie hearing still remained so defective, 
that he was precluded from following any avocation. In the com- 
mencement of June I experimented on this patient with the first 
artificial membrana tympani, composed of Tolcanized india-rubber, 
and the good effect was at once decided. ViTien it was placed over 
the surface of the original membrane, so as wholly to close the ori- 
fice, the patient made a movement of bis lips, and said, " I hear as 
differently as possible from what I have done for many years ; every- 
thing sounds clear !" This patient went away with the artificial 
membrane in his ear, hearing conversation perfectly. The follow- 




TRE MEMBRASA TYMPANI. 



197 



ing morning lie came to my liouse, saying, that he had accidentally 
moved wliat I had left in his ear, and that " he was aa dull as ever." 
I replaced the artificial membrane, and he again heard well ; and 
being supplied with one which he could introduce or remove at plea- 
sure, he has worn it during the day ever since, and has never com- 
plained of pain or discomfort from it. Latterly, his hearing has ao 
greatly improved, that he has been able to dispense with the use of 
the artificial membrane for a few hoars daily, but he hears much 
better with than without it, Aa a proof of the great amelioration 
that has taken place, this patient told me, that one day, while in the 
country, and using the membrane, he heard voices at a distance, and 
upon going to the place whence they appeared to proceed, he found 
some boys under a hedge, more than a field distant from the spot 
where he heard them. He is going back into the army. 

This patient was shown at a meeting of the Pathological Society 
of London, in February, 1853, The following is the published re- 
port : — '• The artificial membrane having been removed, the mem- 
bers of the Society had the opportunity of observing the perforate 
condition of each membrana tympani. After the removal of the 
membranes, be could not hear, unless loudly spoken to ; but when 
he had replaced them, which ho did with apparent readiness, his 
hearing was excellent." 

Cage II. Each membrana tympani destroffd by meaglet, at four 
years of age; hearing restored by the artificial membrane; great 
SfTitihility to sounds. — Miss B., aged 21, consulted me on November 
9, 1853, on the recommendation of Dr. Grindrod, of Seaforth, near 
Liverpool. The health was good. 

History. — At four years of age, she suffered from an attack of 
measles, which was followed by discharge from the ears, lasting to 
the present time ; so that the ears require syringing every day. 
Since the measles, the power of hearing so greatly deteriorated, 
that she has to be distinctly spoken to within the distance of & 
yard. On inspection, it was found that the membrana tympani of 
each ear had been destroyed, and that the only vestige of it left 
was a very narrow margin. The mucous membrane lining the tym- 
panic cavities was very red, much thicker than natural, and covered 
with a mucous discharge. 

Treatment, — An artificial membrana tympani was introduced into 
each ear, the immediate effect of which was to improve the power of 
hearing so greatly, that the patient heard my voice perfectly well 



198 THE DISEASES OF THE EAR. 

across my room with my back towards her. Ordered to wear the 
artificial membranes during the day, to take them out at night, and 
to .syringe the ears with warm water twice daily. 

18th. — Has been wearing the membranes every alternate day, and 
has heard perfectly while they were worn ; indeed, the only drawback 
to her comfort has been, that her friends still speak loudly to her, 
which causes considerable uneasiness in the ears from the very great 
sound. 

16th. — Continues to hear well ; but has been obliged to remoTe 
to a quiet street, as the sound of carriages passing the hoose has 
been annoying. She complains of the "intolerable rustling of her 
silk dress,*' of which she was never before conscious. The patient 
left London after some furtlier watching, quite comfortably. I re- 
ceived a letter from her in the following December, from which I 
subjoin an extract. 

" I am thankful to say, the improvement in my hearing has in- 
creased almost daily, and I now hear general conversation easily, 
and feel quite a difierent person from what I did a short time since. 
I am still sensitive to sounds, but not nearly so much distressed with 
them as I was at first. I found the noise of the organ at church 
too great the first time I went, and came out almost as soon as the 
service commenced. I find no pain in my ears, and am, in all re- 
spects, in the enjoyment of good health." 

Case III. Deafness of twenty years' duration perfectly relieved by 
the artificial membrane. — The following particulars of a case, con- 
cerning which we corresponded, were sent to me by Dr. Shearman, 
of Sheffield : — " I tried the false drum in one ear ; the whole of 
the merabrana tympani had been destroyed, and the cavity of the 
tympanum so bared to tlie view, that it was difficult at first to 
ascertain whether the drum membrane had gone, or was obscured 
by polypoid or other growths ; however the probe came down upon 
the bone. The false drum gave such relief, that the hearing dis- 
tance was increased from actual contact to twelve, and subsequently 
to eighteen inches : the patient is now able to manage the contri- 
vance herself. 

" The other membrana tympani of the same patient is yet so 
covered with polypous growths, that I cannot make out the precise 
condition of the drum ; however, inflation of the tympanum shows 
that the membrana tympani is perforated. The deafness in this 
case is of nearly twenty years' duration, is perfectly removed on 



THE MEMBRANA TVMPANl. 



li)9 



the left side, and altLough the whole of the left membrana lyrapani 
is destroyed, the false one acts perfectly." 

Case IV. Destruction of each membrana tympani; stricture of 
the meatus. — Miss S., aged 24, not in very good health, states, that 
at four years of age she suffered from an attack of scarlet fever, 
subsequently to which she became so hard of hearing, as to need to 
be distinctly spoken to within the distance of a yard. This hard- 
ness of hearing is increased during cold and damp weather : has 
had discharge from both ears, but at present it is only very slight 
from the left, which is the better car. Complains of no pain, but of 
a noise. Lately, from not being Ln good health, the hearing has 
been more than usually dull. 

Exaviination. Right Ear. — Hearing distance of watch, half an 
inch. The central part of the meatus is contracted to less than half 
its natural size. A very strong light having been thrown beyond 
the contracted portion, part of the mucous membrane of the tympa- 
num could be detected ; but there was no appearance of the mem- 
brana tympani. 

Left ear. — Hearing distance, one inch : meatus contracted as in 
right ear ; the membrana tympani was not seen, but in its place the 
shining tympanic mucous membrane was observed. 

At first sight it appeared as if the presence of the stricture would 
offer an obstacle to the introductioii of the artificial membrane. I 
nevertheless tried a small one to each car, passing it through the 
stricture, and then moving it gently to and fro, so as to allow it to 
recover its plane surface. Having done this, I moved it slightly 
forwards to the situation of the natural membrane, and immediately 
the patient heard perfectly all that was said at any part of the room. 
There was little difference between the hearing power of the two ears. 
Care was required in the management of the case, from a slight ten- 
dency to irritation of the meatus ; but the patient left me hearing 
well. In the middle of February, 1854, the mother of this lady 
being in London, called to thank me for the benefit produced in her 
daughter's case. She said that her daughter " continued to hear 
perfectly, and that she was quite an altered person." 

Case V. Deafness from scarlet fever during jive years; hearing 
completely restored by the use of the artificial membrane. — Miss G., 
aged 14, was brought to me, in August, 1853, by Dr. Grindrod. 
Health good. 

History. — ^When between nine and ten years of age, suffered from 



THE DISEASES OP TOE EAE. 



scwrlct fever, since which time, has had a discharge from both e 
attended by such a decline of the hearing as to require her to be 
loadly spoken to very near. She baa lately been to a sehool at 
Brussels, where her defective hearing had greatly hindered her pro- 
gress. On inspection, it was found that the mcmbrana tympani of 
each ear was absent, while the mucous membrane of the tympanum 
was thick and red, and poured out a mucous secretion. An itrtifi- 
cial membrana tympani was applied to each ear, and produced so 
complete a restoration of the hearing power, that the patient could 
detect all that was said in different parts of a large room. This pa- 
tient returned to school at Brussels, and in about sis weeks after- 
wards, I received a letter from the fatlier, a medical man, from which 
the following ia an extract : — 

" We have had the most pleasing intelligence from my little 
daughter at Brussels, respecting her hearing. I think I cannot 
do better than to give it in her own words : — ' I have had thre« 
German doctors, and one French one, to see me, or rather the arti- 
ficial membrane. I am quite a new creature, my hearing is ao 
greatly improved.' " The father adds, " This is very satisfactory 
evidence as to the successful operation of your beautiful invention, 
after nearly five years' deafness to the extent, that she was unable 
to hear a word in ehurch the whole of the time." 

Cast V. Deafness for twcnti/j/ear», from measles and acarht fever, 
greatly iviproved hy the artificial membrane. — Mr. M., aged 23, con- 
sulted me 20ih December, 1853. Health good. No relatives deaf. 

History. — At three years of age had scarlet fever and measles at 
the same time, accompanied by much discharge from each ear ; vaa 
totally deaf for some months after the attack, but slowly improved, 
so as to hear a loud voice spoken near the left oar; the right ear 
nearly useless ; lately has heard better at times with the left ear for 
two or three hours. To-day requires to be spoken to loudly within 
two feet of the left ear, and is about the same as usual. On exami- 
nation of the right ear, the meatus was found to contain a collection 
of mucus and epidermis, which being removed the membrana tym- 
pani was seen to be white as paper, flat and thick : posterior to the 
inferior third of the malleus is a small orifice, about three-quarters 
of a line in diameter, through which mucus oozes from the tympanic 
cavity. Watch not heard even when pressed against the ear ; but 
the crack of the nails -was distinguishable. 

Left ear. — The meatus contained a shreddy discharge ; the mem- 



201 



brana tympani waa absent ; the mucous membrane of the tympanum 
red and much tumefied. Watch heard when in contact with the ear. 
Although the hearing power of iLe left ear was somewhat lees than 
in the majority of cases where there is an absence of the mcmbrana 
tympani uncomplicated with any other disease. I, neverthelcBs, de- 
termined to try the artificial mcmbrana tympani, tlie effect of which 
was to improve the hearing considerably, although not to the same 
extent as in the majority of cases. 

Dec. 21st. — Ordered to wear the membrane for four hours. 

22d. — Upon using the membrane to-day, heard my voice distinctly 
half across my room, 

27th. — Says that he never remembers to have beard so well as 
yesterday ; beard everything that waa said at dinner, and his own 
voice quite distinctly: the sound of the rustling of a lady's silk 
dress quite astonished him. Towards the latter part of the day did 
not hoar quite so well ; and last night, after removing the drum, was 
exposed to cold, which caused some pain. Without the drum to-day 
could not hear my voice, unless I spoke in bis left ear ; with it, 
heard much better, but not so well as yesterday, which arose from 
the mucous membrane of the tympanum being much tumefied. This 
tumefaction gradually subsided, and the patient left me a few days 
afterwards, hearing quite well. lie inserts the artificial membrane 
himself, wbiuh requires some care in its adjustment. On one occa- 
sion, when he started for a walk in the street, after having inserted 
the membrane, his bearing was far from good ; but as he walked on 
the pavement, a sudden movement took place in the ear, and he 
heard perfectly. 

In a letter of February, 1854, this gentleman says : " I have 
much pleasure in informing you that the artificial membrane con- 
tinues to he effectual ; my friends are much gratified at the improve- 
ment you have been able to effect." 



(6.) RUPTURE OF THE MI^MBBANA TYMPANI. 



Previous to speaking of this affection, it seema to me desirable to 
make some remarks upon the functions of the membrana tympani 
and chain of ossicles. 

I. The Articviation of the Stajjes. — The stapes is generally de- 
scribed by anatomists as being connected with the margin of the 



THE DISEASES OF TOE EAB. 



fenestra ovaliB by a simple membrane. Sir Anthony Carlisle, is 
hiB paper on the PhyBiology of the Stapes, merely speaks of " 
membrane which connects it to the edges of the fenestra vestibuli."' 
Professors Sharpey and Quain agree with Sir A. Carlisle. They 
flay, " The annular ligament of the stapes connects the base to tlw 
margins of the foramen fenestra ovalis. The fibres of the ligamemt 
are covered, on the outer side by the mucous lining of the tympaamn, 
and on the inner side by the membrane of the vestibule."' Mr. 
Wharton Jones describes this ligament as springing " from the mar- 
gin of the vestibular fenestra, and it is inserted into the jutting 
margin of the base of the stapes ail round.' Soimmeriug seems to 
Lave had a different view respecting this articulation. He saya, 
" A thin articular capsule connects the base of the stapes to tlio 
fenestra ovalis."* 

If the circumference of the base of the stapes be carefully exa- 
mined by means of a lens magnifying between three and four 
diameters, it will be apparent that, instead of a fine margin only, it 
presents a distinct surface which, when in situ, looks towards ttta 
border of the fenestra ovalis, and is separated from the inner and 
outer faces of the base by well-defined margins. The circiim* 
ferential surface of the base varies in breadth : the broadest part 
has its surface inclined obliquely baetwards and outwards ; mea< 
Bures about a third of a line at its centre ; and gradually narrowi 
as it becomes continuous with the superior and inferior Burf&ceM 
The anterior extremity of the surface is not so broad as the postA* 
rior, and, instead of being oblique, is slightly rounded. The appef 
and lower surfaces of the base of the stapes arc narrower than eithal 
the anterior or posterior portions, and their middle part is the n 
rowest. "When examined in a recent ear the circumfereDtiaS 
surface of the base of the stapes is found to be quite smooth^ 
and covered by a very delicate layer of cartilage, which, 
touched by a fine probe, communicates a soft sensation to the Sngerii 
This cartilage consists of oval corpuscles, very like these in ordinary 
articular cartilage, though much smaller, and is most abundant a 



■ PhiloeophiB&l TnnuotioTU, p. 201. 
• Blcmantary Anfttom;, p. SiO. IBil 
' OjclopiediB of Aniloroy and Physiol 
' De Corporia Uumsni Fobrion, lomo 
lUt*<, Ib*C B«Qim«riDg wu wrong in 



*p«>ki of Iha UguuoutUDi liiuiaUn only. 



jgy. rnl. ii, p. 54S. 

eedunilui, dc Ligsmentls Ouinm. p. 10. 
regarding this tiguuent u ■ eapnila. 



THE MEMBRANA TYMPANI. 



the two extremities, from which portions can often be removed, es- 
pecially in young persons, for examination by the microBcopo. The 
surface of the fenestrii ovalis to which the circumferential base of 
the stapes is applied, is larger than that of the stapes ; nor docs its 
posterior surface quite correspond in direction with that of the stapes, 
but looks directly forwards, instead of obliquely inwards and for- 
wards, to face the stapes, which, as stated, inclines backwards and 
outwards. The articulating surface of the fenestra ovalis is smooth, 
very compact in appearance, seems to have no cartilage upon it, and 
is bounded by two well-defined ridgfls. The circumference of the 
base of the stapes is attached to that of the fenestra ovalis by means 
of two membranes or ligaments. The inner, or vestibular ligament, 
passes from the inner margin of the fenestra ovalis to the inner 
margin of the circumference of the base of the stapes ; and the 
outer ligament passes from the outer margin of the one to the outer 
margin of the other. These two ligaments have between them a 
space which may be called the articular cavity, as it contains enough 
fluid to lubricate the articulating surfaces of the bones. By the 
action of the tensor tympani muscle, the base of the stupes is 
pressed inwards towards the vestibule, as a piston in its cylinder : 
and as soon as the muscle ceases to act, the ligaments Just described 
being elastic, draw the base of the stapes out again. 

n. Movements of the Stape». — The stapes b moved by two mus- 
cles, the tensor tympani and the stapedius. Anatomists seem agreed 
that the action of the tensor tympani is to press the stapes directly 
inwards towards the cavity of the vestibule, and the general opinion 
appears to be that the stapedius muscle merely assists the tensor 
tympani. Thus Mr. Wharton Jones says: "The first action of this 
muscle (the stapedius) will be to press the posterior part of the base 
of the stapes against the vestibular fenestra. At the same time, the 
long branch of the incus wilt be drawn backwards and inwards ; and 
the head of the malleus being, by this movement of the incus, pressed 
forwards and outwards, its handle will be carried inwards, and the 
membrana tympani thus put on the stretch. Breschet calls the 
muscle of the stapes a laxator, but I do not know on what grounds."' 
Professors Todd and Bowman write : " In contraction it (the stape- 
dius muscle) would fix the stapes by pulling its neck backwards. 
It probably compresses the contents of the vestibule."' Ellis states 



204 



THE DIBEASES OF THE BAR. 



that "it assists in retaining the stapes applied to the feneatm 
ovalis."' Miiller writes ; "Tin? influence of the stapedius muscle 
in hearing is unknown. . ■ . The only effect which it appears to 
could be ascribed to it, would be to render tense the membrane by 
which the base of the stapes is connected with the margin of thtf 
fenestra."' 

On account of the smallnesa of the stapedius muscle, and the verf 
slight degree of movement it produces, there is difficulty in deter* 
mining in what way that muscle influences the contents of the ve*' 
tibule. As the tendon of the stapedius, in its course forwardjy 
passes slightly upwards, there is good reason to infer that it di-Hwi 
the neck of the stapes backwards and slightly downwards, and thai 
it produces it slight rotation of the base. That this rotatory more' 
ment of the stapes has the effect of somewhat withdrawing its hose 
from the cavity of the vestibule is, I think, shown by the followisg 
experiment. The tympanic cavity and stapedius musde being ex- 
posed, and the stapes left in situ, by means of a smali pair of cut- 
ting forceps a section is to be made through the cochlea, a portion 
of which should be left in connection with the vestibule. The seals 
vestibuli of this portion will be seen filled with fluid as far as the 
margin of the section; and this fluid is of course continuous with 
the perilymph in the cavity of the vestibule. If the stapedius muscle 
be now pulled, or if the neck of the stapes be gently moved back- 
ward, the fluid in the exposed sac of the scala vestibuli will be oV 
served to recede slightly into the scala vestibuli, and its surface to 
become concave ; as soon, however, as the stapes is allowed to re- 
turn to its quiescent state, the fluid repasses into and fills the seals 
vestibuli, assuming a rounded surface. Independently of thus act- 
ing on the contents of the vestibule, the stapedius muscle producea 
a slight relaxation of the membrana tympani. This is effected by 
the neck of the stapes, in the act of rotation, passing outwards afl- 
well as backwards, and thus gently pressing outwards the inferior 
extremity of the incus ; so that the body of the latter bone puses 
inwards, carrying with it the head of the malleus, and neccssit&Ui^ 
the long process of the latter bone and the membrana tympani to 
pass outwards. It would therefore appear that the stapedius muscle 
acts as the direct antagonist of the tensor tympani muscle ; the 
former relaxing the labyrinthine fluid, the membrana fenestne 



k 



THi: MEMBRA 



205 



rotundae, and the membrana tjnipani ; and tbe latter reudcring 
tense the labyrinthine fluid and the two memhranee. This view is 
supported by the fat-t that the stapeiliua muscle is supplied by a 
branch from the portio dura nerve, and the tensor tympani from the 
Otic ganglion.' It seema to me fair, therefore, to infer that the 
function of the tensor tympani muscle is to protect the membrana 
tympaiii and the labyrinth from injury by loud sounds, while the 
stapedius muscle places these structures in a condition to be im- 
pressed by the most delicate vibrations ; and it would appear to be 
brought into action during the process of listening. Instances are 
not uncommon in which these two muscles are unable to act promptly, 
and the unpleasant consequences are manifest. Thus the loud noise 
produced by suddenly and unexpectedly firing a cannon near a per- 
son, by not permitting the tensor tympani to contract in time, causes 
frequently a sensation of singing or buzzing in the ears, produced 
most probably by a concussion of the expansion of the auditory 
nerve : sensations which sometimes endure for many years. Cases 
are not unfrequent in which the mucous membrane of the tympanum 
is thickened, and a great amount of dulness of hearing is the conse- 
quence. Many patients thus affected hear sounds (the human voice 
for instance) perfectly well when they are listening ; but as soon as 
the act of volition is suspended, the same voice in the same position 
is not perceived. In these cases it vould appear as if the stapedius 
muscle had to counteract the pressure upon the stapes, by the thick 
I membrane. The friends of young persons suffering in this 



I 



■ In ■ddition to Ihc above ili 
b; HoMbke, before alluded to 
tbs ronollDne of th« tUpediua lau^cle (o those juet advanued. An it ia evident, frDin the 
qnat&tioDB fiom wiitera on the eu preriDiul; oited, tbnt Ihoie rievs hare not been enter- 
tuned, I h&ve not Bcmjded to give m; rfliBurehes at length. The fallowing are Uuacbke's 
worda : ' ' While it (tbs Blapediaa mascle) ptetre-t (he posterior eitiemit; uC the boee of 
tbe aU-fei open the poaterioi [mrt of the border of tbe fenestTs otiIIb, it ViRa the anterior 
extremity of tbi« bane nod eoTera the fenentia. At the aame time, the deKending branch 
of the inoDi, with the Mapei, ia drawn baokward). by which the bodj of thia bone preiaea 
the roalleui forwardi , and, u iti handle reBti Dpon the menibraaa tympani, it relaxea it. 
I hate often obBenred (hie morement of tbe matleuB when I mored the long hrunoh of the 
ineiu in the direetioD at the tendon of the mu»te of the stapeg. I thut regard the luller 
M relaxing the Ijmpannm and openiai; the labyrinlh ; that is to mj, according to tbe 
Tiew of Treiironos, it ig the ontagonint of the teneor lympanl muaclea. The two have 
altogether mnch analogy : the; describe an arvh loolting upwardr, pan ocer a kind of 
poHey. and ore contained in an obmoui canal ; bat they have alio opposite functions : the 
■tapediui! muaole poaeea fruui behind furwarde ; tbe teneor tympani from befure bockoards ; 
the eUpediua receiies ila nene from the facisl, tbe tensor tympani from (he fifth."— 
Euqfe/opcdit Analamiqui, tome T, pp. 782, T83. 



manner, often imagine thut there is no real dulnese of hearing, 
simply a want of attention ; the fact being that the power of bear- 
ing certain sounds bos coascd to be involuntary with these patients, 
and can only be exercised by a strong effort of the will. 

The tensor tympani muscle appears to be of use not merely in pr*- 
venting the membrana tjmpani and labyrinth from being itijurcd by 
powerful sonorous vibrations, but also in protecting theec orguta 
from the forcible pressure of air or of a foreign body. Thus the 
membrana tJ^npani offers considerable resistance to the pressure 
of a foreign aubgtance which has been slowly introduced into tba 
meatus ; though the sudden and unexpected contact of a similar 
body often produces extensive laceration of it. Again, a violent 
blow on the ear with the palm of the hand, rarely produces mischief 
to the membrana tympani when its reception is expected ; whereas 
a comparatively gentle bnt unexpected blow, frequently produces 
not merely concussion of the nervous labyrinth and serious derange- 
ment of its functions, but not uncommonly ruptures the membr&M 
tympani itaelf.' 

The preceding observations indicate that one function at least of 
the ossicles and musclea of the tympanum and the membrana tyro< 
pani, is to act as the analogue of the iris in the eye, and to regulate 
the amount of sonorous undulations that are to pass to the labyrinth. 
This view has already, to a certain extent, been alluded to by pre- 
vious writers. M, Savart, in the course of bis very interesting re- 
searches upon the functions of the membrana tympani, arrived at a 
somewhat similar opinion ; although ho omitted to point out the 
manner in which the muscles acted on the labyrinth and membrana 
tympani. He says : " Les osselets ont encore pour fonclion de mo- 
difier I'amplitude des excursions des parties vibrantea des organes 
contenus dans le labyrinthe,"* Mr. C. Brooke, in a Lecture delivered 
at the Royal Institution, in the year 1843, says : This osseous ar- 
rangement may be considered to perform an office in the ear analo- 
gous to that of the iris in regard to light; namely, that of regulating 
the tension of the various structures that are thrown into a state of 



■ I nuiy mention a ckm illoatretiTB of the ■bore gUtement. 


The Grat that of iin •HoinaM 


physioinn in London, who, whils pinjing with hii children, reo 


rlTpd B blow on one mw from 


tha hflnd nf OD. of thtin coming laddenlf kod rDfidl]' in eont> 


t with it : from th&t time ts 


tbcprsHnt (an inlerTiiIof four to Bve )'B«ri) them bu been a 


ooDitsut fidgiuK in that «w. 


• Keeherohes >oi len Vngn de la Membmna da Tjmjan el 


del'Oreille Eitern» par H. 


P«lil B»v«rt. Lb 1 l-Aoidemie Royde del Scienoei, la 211 A 


Til. Ig22. Jouruilda Ph;. 


•Wogla, par F. Majendie, lomt it, p. 1B3. 






THE MEMBRANA TYMPANI. 



207 



vibration, according to the pitch and intensity of the sound to be 
transmitted to the sentient nervous fihres. This is effected by the 
conjoined action of the tensor tympani and stapedius muscles, by 
which the tympanum would be rendered more tense, and a simulta- 
neous change in the position of the stapes would alter the tension 
of the fluid throughout the labyrinth, and therefore also the tension 
of the membrane of the fenestra rotunda, which intervenes between 
that fluid and the air in the tympanic cavity."' Professors Todd 
and Bowman state that there is "much reason to suppose that the 
tensor tympani muscle is analogous in its use to the iris, and des- 
tined to protect the organ from too strong impressions."' 

The first effect of the destruction of the membrana tympani gives 
weight to the opinion here advocated. Mr. Busk has detailed to me 
the particulars of a case in which, for a few days after the destruc- 
tion of the membrana tympani, a patient was unable to endure the 
whistling of anolhcr in an adjoining bed ; and Cheselden says, " that 
after destroying the tympanum in both ears of a dog, for some time 
it received strong sounds with groat horror."* 

Pathological Obgerrations. — There are several modes in which the 
membrana tympani may be ruptured. The most common is an nn- 
expected blow on the ear. It may also be ruptured by having a 
foreign body forced through it ; by very loud sounds ; by a fall ; by 
violently blowing the nose ; or by vomiting. Mr. Wilde relates a 
case in which the membrana tympani was ruptured by a gentleman, 
while bathing, thrusting his little finger into the meatus to dislodge 
some water. 

In cases of simple rupture, as from an unexpected blow on the 
ear, the margins of the orifice are usually in contact, scarcely any 
hemorrhage occurs, fibrin is effused, and the rent is speedily re- 
paired. Where, however, the margins of the membrane are no 
longer in contact, and where the membrane has been much strained, 
very great irritation may ensue, requiring active anti-inflammatory 
measures. The most serious cases arise from the injury inflicted by 
the introduction of a foreign body, since the dermoid layer usually 
participates in the disease. 

In cases of simple rupture of the membrana tympani where in- 
flammatory symptoms are still present, it is not desirable to do more 
than introduce a portion of cotton-wool into the meatus, to prevent 



208 THE DlSEASEti OF TUB EAR. 

loud sounds from aoting injuriously upon the drum. Where tlie in-l 
flammation is great, leeches must be applied below the ear, and to 
the margin of the orifice of the meatus, and evaporating loljona 
used to the margin of the meatus itsetf. Should these remedies be 
unsuccessful, counter-irritation must be applied orer the mastoid 
proceaa. 

Ca»e I. Membrana tympani ruptured by an unerpecicd box on the \ 
ear. — Master G., aged 14, wa8 brought to me on June 2, 1852, on I 
account of a peculiar sensation iu the left ear whenever he blew his | 
nose. 

Hutory. — Fire days ago, as he was sitting still, his tutor o 
quietly behind him, and suddenly and unexpectedly gave bim ft J 
gentle box on the left ear, which produced instantaneous pain deep J 
in that organ. On using his pocket-handkerchief afterwards, he ex- 
perienced a tingling and clicking in the ear, in which he has gjnoe 1 
also had pain at times, and from which occasionally a drop or two 
of blood have escaped. Inspection showed a small orifice at the 




■ eai 



An A|jenare in Oib lowf r part of llie left Memlirnna T_vmj>imi, from mptiw 

lower part of the membrana tympani, about a line in diameter, wift ' 
white borders. Air passed through on holding the nose and blow- 
ing gently. The watch was heard at the distance of a foot. As 
there was some slight pain, a leech was ordered to be applied below 
the ear every second night. This was continued for ten days, at the 
end of which time the pain had disappeared, the orifice had closed, 
and the hearing power had returned. 

Cage II. Rupture of the membrana fympani by a blow on the ear 
with a boUter. — Master K,, aged 14, was seen by me in consulta- 
tion with Mr. Keal, on Deccmher 20, 1855, on account of an un- 
pleasant sensation in the left ear, 

Hiitory. — A week ago was engaged in a " bolstering match" at 
school, during which he received a blow with a holster on the left 
ear, which caused him pain. In the morning, on using his pocket- i 



MEMBKANA TYMP 



209 



handkerchief, he found that air ruahed out of the left ear, eo that 
he was ohliged to place his finger upon the ear while using the hand- 
kerchief. On examining the ear, ii rent was observed in the mem- 
brana tympani, running from the lower extremity of the malleus 
downwards to the inferior parts of the membrane. The margins of 
the rent were in contact, but the air paased through with the 
slightest pressure from the fauces. The hearing power was natu- 
ral. He was ordered a little evaporating lotion to apply on cotton 
to tlie orifice of the meatus. Twelve days afterwards, the margins 
of the orifice were observed to be swollen, and a small coagulum of 
blood attached to them: air passed into the tympanum from the 
fauces, hut it did not escape through the aperture. When I saw 
this patient after another fortnight, the orifice was closed, but the 
cicatrix remained. 

Ca»e III. Membrana ti/mpani ruptured hy blowing the nom 
forcibly. — Miss S. A. N., aged 16, consulted me on February 5, 
1850, for pain and discharge from the right ear, accompanied by 
dnlness of hearing in both ears. Her friends stated that she had 
for a long time the habit of blowing the nose very violently ; and 
when doing so, four or five months ago, she felt aa if something had 
given way in the right ear, and since that time has had discharge 

Fio. 7i. 



Aa ApartDTe in tha poalr 



>S thn rigbt MgmbrnaiL Tjmpani, from rupture. 



from it. Whenever the nose is blown, air rushes out of the right 
ear with a. loud squeaking sound. On examining the right ear, the 
membrana tympani was observed lo be covered with mucus ; and 
when the nose was blown, air was observed to issue from the tym- 
panic cavity through a valvular fissure at the posterior part of the 
membrane. Watch heard at a distance of two inches. The treat- 
ment consisted in applying leeches to the margin of the meatus, in 
syringing out the ear with a weak solution of liquor plumbi in water, 
and in keeping up a slight discharge from the surface of the mastoid 
process. It was, however, only by slow degrees that the discharge 
U 



210 



THE DISEASEe OP THE EAR. 



dimmisbed, and the orifice in the membrane closed. The raem- 
brana tympani did not regain ita natural appearance, the part of it 
posterior to the malleus having fallen inwards towards the promon- 
tory. 

Ca»e rV. Rupture of the membrana tt/mpani by a tung: tt\^my 
to chorda tympani nerve. — J. L., Esq., aged 19, consulted me on 
September 25, 1856. A week previously, while engaged in shooting, 
he was endeavoring to force bis way through a hedge, and turning 
sharp round, with the view of picking up a bird, a twig passed 
into the right meatus, producing a sudden and severe pain at some 
distance in, followed immediately by deafness and a little bleeding, 
which has continued to a slight extent every night since. A bus- 
zing noise in the ear supervened soon after the accident. The paia I 
speedily subsided. On examining the right meatus, a little coagu- I 
latcd blood was found; on removing which by the syringe, the mem- 
hrana tympani presented a rupture extending through the greater I 
part of ita diameter, a little posterior to, and parallel with, thtt I 



Ad AperlDre In the light Mei 



handle of the malleus. The edges of the orifice were red and 
swollen. Air passed through it when the tympanum was inflated, | 
Watch only heard on contact. A leech wa.s applied to the orifice J 
of the meatus ; and a mildly astringent gargle applied gently fey | 
the syringe, twice a day. On October the 4th, the orifice had J 
entirely healed ; the buzzing noise liad almost ceased ; the hearing I 
distance was half an inch. This patient returned to India, but I 
intelligence has been received that the hearing has greatly i 
proved. 

For days after the laceration of the membrane in the above c&se, I 
there was a feeling on the same side of the tongue as if something I 
cold had been rubbed over it ; the taste on that side also was im- 
paired. The tongue, however, was quite natural in appearance and \ 
movements, and its sensibility to touch was the same on both sides, i 




TOE MEMilHASA TYMPANI. 211 

Cage V, Rupture of the membrana ti/mpam by the hinting of a 

gun. — W. S., Esq., aged 28, consulted me in September, 1856, Six 
days ago was shooting, wlien the giin burst in bis bund, producing 
instant deafness in the left ear, followed, two days ago, by a copious 
discharge of a watery character. Yesterday there was a slight 
aching pain, and for two or three days every pulsation of the vessels 
has been heard in the left ear. On examination, the left meatus was 
found to be red and to contain purulent discharge; the membrana 
tympani was also red, and presented an aperture at its upper and 
posterior part of an oval shape, about a line in length, and nearly & 
line in breadth, as if a portion of thcmembrane had been destroyed; 
the mueous membrane of the tympanum was red, and the hearing 
distance four inches. A leech was applied occasionally to the mar- 
gin of the orifice of the meatus ; the car was kept clean by daily 
syringing ; and afterwards a lotion, the nitrate of silver (gr. x. ad 
5j) was applied on cotton-woo], by means of a probe, to the surface 
of the membrane. The aperture slowly filled up, as if by the de- 
posit of fibrin on the margins, which, for some time, were thicker 
than the surrounding portion of the membrane ; and, in the course 
of BIX weeks, it was entirely closed, and the hearing power perfectly 
restored. 

In this case the right membrana tympani was previously ruptured, 
and the bursting of the gun produced no effect upon the oar. 

The following ia a tabular view of the condition of the membrana 
tympani in the dissection of 1013 diseased ears ; — 

"l*!"'' 15 



Inner auirnoe adhcT. 



iromonlory by b»nd! of ni 



pnrfiicD ndberont 



I onictaa knd the 



er snrritce m 
>r BDrfacg m 



atural, in<l opnqne, S 

ituril, Rnd think uid apkqae, ... I 

aturml. and mSt, I 

itnral, uid teiiH, ..... S 



212 THE DISEASES OF THE EAB. 

Very conoave externally, and the inner surface in contact with the promon- 
tory • . . .10 

Very oonoave externally, and the inner surface connected to the promontory 

by bands, . . • .13 

Very ooncaye externally, and the whole of the inner surface in contact with 

the inner wall of the tympanum ; the tympanic cavity being obliterated, 7 
Very concave externally and thick, and adherent to the promontory, . . 3 

Thicker than natural, .66 

Thick and unyielding, .5 

Thick and white, .12 

Thick and soft, - .2 

Thick and tense, .5 

Thick, and attached to the incus by membranous bands, ... .1 

Thick and vascular, and connected to the incus by bands, ... .1 

Thick and opaque, .4 

Thick, tense, and congested, • • . . 2 

Containing deposits of calcareous matter, .14 

Containing spots of cartilage, .2 

Flat, externally, .6 

Flat, thick, and white, .4 

Epidermoid lamina thick, .8 

Epidermoid lamina absent, .5 

Dermoid lamina very vascular, .1 

Dermoid lamina very thick, .4 

Dermoid lamina very thick and vascular, .3 

Dermoid lamina detached from the fibrous laminse, . . - . .1 

Radiate fibrous lamina absent, entirely destroyed by ulceration, . . .3 

Radiate fibrous lamina absent in parts, ..*.... .2 
Dermoid and fibrous lamince absent in parts, apparently from ulceration, . 3 
Radiate and circular fibrous lamina; destroyed by ulceration in parts, . . 6 
Radiate and circular fibrous lamina) entirely destroyed by ulceration, . . 4 

Radiate and circular fibrous lamina) entirely destroyed by ulceration ; the 

mucous lamina being attached to the promontory, .... .2 
Radiate and circular fibrous laminse containing pigment cells, ... 3 

Mucous lamina thick, .2 

All the laminse destroyed by ulceration except the epidermoid, ... 3 
All the laminse destroyed by ulceration except the mucous, .... 2 

All the laminae perforated, .......... 47 

All the lamina) absent apparently from ulceration, .... .21 

All the laminae perforated, the remaining portion of the membrane being ad- 
herent to the promontory, ........ .9 

All the laminae perforated, and very thick .1 

All the laminae perforated, very thick and concave, and adherent internally 

to the promontory, .......... .2 

All the laminae perforated by molluscous tumors, .2 

Upper part of all the laminae detached from the bone, .... .2 

The circular cartilage exposed, .2 




THE EUSTACHIAN TUBE. 



Anatomical Observations. — Tlio Eustachian tube, extending be- 
tween the cavity of the fauces and that of the tympanum, is from an 
inch and a lialf to two inches in length. At its faucial orifice it is 
wide and dilatable, but it soon becomes so constricted as barely to 
admit an ordinary -si zed probe. Its direction from the tympanum 
is obliquely downwards, inwards, and forwards. 

The Eustachian tube consists of two portions, the osseous and 
fibro-eartilaginoiu : the osseous portion e.ttends from tlie tympanic 
cavity to the fibro-cartilaginoua portion ; and is about three-quarters 
of an inch in length, and about a line in diameter. It is lined by 
an extremely thin fibro-mucous membrane, very similar to that 
lining the tympanic cavity., 

The fibro-cartilaginous portion, as its name implies, consists of 
cartilage and fibrous tisKue, and is about an inch in length. It is 
of a conical form, having its apes continuous with the osseous por- 
tion, while the base extends into the cavity of the fauces in the 
shape of a rounded tubercle. On examination, the rounded extre- 
mity of the cartilaginous portion is found to form a superior and 



inferior )ip : the former projects ftlightly ilonnwards, and forms the 
the upper wall or anglo of the tube ; the latter turns slightlj' up- 
wards, and forms the inferior angle. The fibrous membrane form- 
ing the outer wall of the tube is attached, above and below, to the 
two lips just described; forming anteriorly a free border, and poste- 
riorly being attached to the anterior border of the outer part of the 
osseous portion. The trump et-ehaped faucial orifice of the Eusta- 
chian tube is nearly half an incli long ; and its middle part may be 
considered to be on a level with the iuferior meatus of the nose. 

The uee of the Eustachian tube is to allow ingress of air to the 
tympanum, and egi^css of mucus from it ; but the point of import- 
ance which specially claims attention is, whether its guttural orifice 
remains always open, so that the air in the cavity of the tympanum 
is constantly continuous with that in the fauces. The opinion of 
physiologists is in favor of this view. MUller says, that the object 
of its being constantly open is, " that a certain degree of dulness 
which the sound might acquire from the resonance of the apparatus 
is avoided :" and adds that, " Uenle supposes that the air of the 
cavity of the mouth and nose are in like manner evolved through 
the medium of the Eustachian tube, to increase by resonance the 
intensity of sounds entering the ear by the external meatus."* 

Dr. Todd speaks of one object of the Eustachian tube being to 
" afford an outlet for the escape of such sonorous undulations as do 
not impinge upon the labyrinthine wall of the tympanum."* 

Other writers differ in some measure from the foregoing view, 
and some physiologists are not in favor of the constantly pateat 
condition of the Eustachian tube. Thus Mr. Wharton Jones S&y-g, 
" It is to be remarked that the Eustachian tube is not habitually 
wide open, so that the air can flow freely in and out, but that, 
on the contrary, in the state of rest its walls are collapsed. By 
this arrangement, which gives the Eustachian tube the property 
of a weak valve, opening either way, the too ready course of the 



Ilyrtl agrees in the above statement, and aays, " The walls of 
the convoluted trumpet are disposed to lie upon each other and 
form mucous adhesions, so that, as any one can easily satisfy 
himself, a considerable degree of compression of the air in the 

' Mailer's Pbfilolof^, tnuisUted by Bal;. vol. ii, pp. 1170-1273. 

> Cjol DpBiiliii <if AnatoDi; and PhjEiology, article " Hearing," p. bXt. 

• CjBlopted'M or Sargerj, p. S3. 1841. 



THE EDSTACHI 



mouth and nose (by means of the muscles of the cheek, the mouth 
being shut) is necessary to force air into the cnvittis tjinpani."' 

In a paper laid before the Royal Socioty, in 1853, I endeiii'ored 
to show that, in the state of repose, the faucial orifice is always 
shut ; that the means by which it is opened are the muscles of the 
palate; and that it is opened during the act of deglutition. In 
that paper it was further pointed out, that in man and in moat 
mammalia, the muscles opening the Eustachian tube were the tensor 
and levator palati, which have been long known to be attached to 
its orifice. In some mammalia the tube is opened by the superior 
constrictor of the pharynx, and in birds hy the internal pterygoid 
muscles. That the Eustachian tube is usually shut, and the act 
of swallowing is the process whereby it is opened, is shown by the 
following experiments : — If the cavity of the tympanum be par- 
tially distended with air, by making an attempt at a forcible 
expiration through the nose when the nostrils are held closed, a 
sensation of fulness or pressure is experienced in the tympanum, 
arising from the pressure of the air against the inner surface of 
the membrana tympani : a sensation, however, wliich does not dis- 
appear as soon as ordinary respiration is carried on, but remains 
until the act of swallowing is performed, and the air thereby 
allowed to escape. Again, if the mouth and nose be held closed 
during the act of deglutition, the same sensation of pressure in the 
ears is felt : for during that act the air, which is slightly com- 
pressed by the muscles of the fauces, passes into the tympanic 
cavities ; as in the former experiment, the feeling of distention is 
not relieved until the act of swallowing is repeated with the mouth 
and nostrils open. A third example, proving the Eustachian tubes 
to be opened during the act of deglutition, and closed when the 
muscles of the fauces return to a quiescent state, is afforded by a, 
person descending in a diving-bell. It is well known that during 
the descent the compressed air filling the e.xternal meatus produces 
a sensation of weight, and often of pain, by pressing the membrana 
tympani inwards. This sensation can, however, be at onced eased 
by an act of swallowing, whereby the condensed air is allowed to 
enter the tympanum through the Eustachian tubes, and thus afford 
support to the inner surface of the membrane. A further proof 
that air enters the tympanic cavity during deglutition with the 

e Gtharargon d«> MiDMhsD und der Smug- 



216 THE DISEASES OF THE EAB. 

nostrils closed, and passes out again during the same act with the 
nostrils open, is obtained by the inspection of the membrana tym- 
pani in the living person, by means of a strong light, during the 
two operations : in many instances, the membrana tympani is seen 
to be pressed slightly outwards by the first act, and to return to 
its previous state during the second. 



ON THE MUSCLES WHICH OPEN THE EUSTACHIAN TUBE. 

Valsalva,^ in his admirable treatise on the human ear, appears to 
have been the first anatomist who pointed out the fact, that the 
tensor and levator palati muscles take an origin from the £ustar 
chian tube ; he also gave them the appellation of the muscles of the 
Eustachian tube ; but he considered that their function is to keep 
the tube constantly open, as he believed that "if the tube is closed, 
the hearing is lost at once." 

Most modem anatomists have described the muscles of the soft 
palate as taking their origin from the Eustachian tube ; but they 
have not ascribed to them the function of opening or of otherwise 
affecting the tube. 

As stated, the two muscles which open the tube in man are the 
tensor and levator palati. 

The tensor palati muscle arises from the fossa at the root of the 
internal pterygoid plate, from the adjacent bone, from the outer sur- 
face of the superior cartilaginous lip of the Eustachian tube, and 
from the membrane forming its outer wall ; and the fibres from 
these several sources pass downwards, form a flat muscle which 
winds round the hamular process of the sphenoid bone, to be in- 
serted into the aponeurosis of the palate, and into the ridge of the 
palate bone. 

The levator juilati muscle arises from the inferior surface of the 
petrous bone, near the apox, and from the outer half of the under 
surface of the cartilaginous j>ortion of the tube ; and the fibres de- 
scend in contact with the inner half of the under surface of the tube, 
and are inserted into the aponeurosis of the palate, some of the fibres 
uniting with those on the opposite side. 

The action of the tensor palati muscle, when it contracts, is to 
draw slightly outwards, and to keep on the stretch, the membrane 

* De Aure Humana Tractatuii. 1735. 



THE EUSTACE 



217 



forming the outer wall of the Eustachian tube ; the action of the leva- 
tor palali musch ia to draw downwards and keep tense the lower 
wall of the tube; hence it will be seen that the combined nation of 
the two muBclee is to keep open the tube by drawing the membrane 
forming its outer wall apart from the cartilage forming its inner 
wall. 

As during the act of deglutition the tensor and levator palati 
muacles contract, it is evident that whenever that act is performed, 
the Eustachian tube must be opened; and inasmuch aa there is no 
apparatus by which the faucial orifice of the tube can be kept open, 
its lips must fall together, and the orifice close as soon as the muscles 
cease their action. During the few moments that the faueial muscles 
are brought into play in the process of deglutition, air can either 
enter or recede from the tympanic cavity, and thus be always of the 
same density aa the outer air. The reasons why the Eustachian 
tube is closed, save during the momentary act of deglutition, are, 
first, that the tympanum may be generally a closed cavity, so that 
the Bonorous vibrations reaching it may be concentrated upon the 
membrane of the fenestra rotunda ; and, second, that, aa specially 
pointed out hy Dr. Jago, sounds may be prevented entering the tym- 
panum from the fauces.' 

PATBOLOOICAL OBSERVAnOHS. 
Although from the preceding remarks there can remain little doubt 

> An eiaminitlion of tfas fauoisl oriflcs of Urn Eo^taoliiui tnbe in other ■aioiiila ia corra- 
bontiTe of the view tbore mlvaDced. In mammalia th« fauclaJ orifice of tbe tubs prc- 
HDta mnab Tarietj both in Btruoture nnd rorm. In lbs ■Dimnli I bitTe disHctcd belonging 



I, Ibere is I 






I opened b^ tbe Tauoial 
nembrKiie 



uid Ihi aperture ii guurded bj u thin fold of eliutic mem 

maeolea. In tbe airnivora the cartilage is promiDent, and forms a dial 

Jeotion. In tbe rodciuia (be orifloe coniial* merely of a timan \a Ibe i 

of the fances. In tomeof tbe mammalia the orifioe ia opened by the laporior conatrlctorof 

tbe pharynx. In all the birilt that I have been nble to examine, the Eustaehiaii tube waa 

tnad Inlo Ibeir eompoaition. The mcmbranons portion uanElnle of a uc, whirh is common 
to both eani. the upper extremity of which receives the two oueona tube*, and tbe lower 
extremity opena into tbe oavity of the fauoei posterior to the aperture of the narei. The 
moMlaa which opan the Baatubiau tube in the bird ure tbe internal pterygoid, oi rather 
nuall miucteB diittnal from tbe pterygoid, bnt aoucSHury to them. Tbe common rnembrB- 

tube are In oontact with, and Bnnly adherent to, the inner lurfaee of theje musclea or tbeir 
aoeeiaorloa, ao that when the flbrea are drawn from the median line the walJi of the lobe are 
■epantod, and a fres commonicatlon «xista between the ^rmpanio oavity and tbe pharynx. 



218 THE DISEASES OF THE EAR. 

that the faucial orifice of the Eustachian tube is ordinarily closed, 
except during the act of deglutition, it is requisite to perfect hear- 
ing that the tube should be pervious, and that there should be a con- 
stant interchange of air in the cavity of the tympanum. If the 
Eustachian tube becomes impervious, the air that was in the tym- 
panum at the time of the closure gradually disappears. It is not 
easy to decide whether it is absorbed, or whether by a kind of exos- 
mose it passes through the membrana tympani ; but whatever the 
cause, in a space of time, varying in dificrent cases from a few honn 
to a day or two, there is no doubt that the air in the tympanic 
cavity becomes partially exhausted. The effect is to produce an 
increased concavity in the external surface of the membrana tym- 
pani ; a forcing inwards of the chain of ossicles ; pressure on the 
contents of the labyrinth ; and a very serious diminution of the 
hearing power. 

The morbid conditions of the Eustachian tube found in 1523 dis- 
sections were as follows : — 

Containing muons, .10 

Containing muen?, lining membrane congested, .2 

Containing maoai>, lining membrane thick, 

Lining membrane oongeittod, 

Faucial portion, mucous membrane red and soft 

Bands of adherion connecting the walls, 

Stricture in osseous part, 

Stricture in cartilaginous part, 2 

Very large, 2 

The causes of obstruction of the Eustachian tube may be thus 
classified. 

1. At its faucial orifice; a thickening or relaxation of the mucous 
membrane. 

2. At its tympanic orifice ; thickening of the mucous membrane, 
or a deposit of fibrin. 

3. In the middle part of the tube; a collection of mucus, a stric- 
ture of the osseous or cartilaginous portions, or membranous bands 
connecting the walls. 

. 1. Obstruction of the Eustachian tube, at its faucial orifice takes 
place — 

(a.) From thickened mucous membrane. 

(6.) From relaxed mucous membrane. 



THE EUSTAC 



(a.) oBSTRUCTIOfI OF THB FADCIAL ORIFICE PBOM THICKESED 
MUCODS MEMBRANE. 

In these coses there is usually enlargement of the tonsils, or 
hypertrophy of the mucous membrane of the nose and fauces. If 
the obstruction occurs in a young person, the mucous membrane of 
the nose is commonly so iliiek as to oBFer some resistance to the easy 
passage of air, and to lead to the habit of breathing through the 
mouth : a habit which at night is carried out to a marked degree, 
and tiie patient often snores loudly. Upon examining the fauces, 
the tonsils are sometimes found enlarged, and the faucial mucous 
membrane is thicker than natural. In the adult the latter condition 
is observed, but the tonsils are less frequently affected. The deaf- 
ness conies on usually rather rapidly, often subsequent to a cold, 
and. after remaining for a time, suddenly vanishes wilh a loud crack 
in the ear. This amelioration often accompanies the acts of yawn- 
ing, gargling, or other strong muscular effort of the fauces. The 
improved hearing which thus results rarely continues long ; some- 
times it lasts for a few hours, in others for a day; a variation which 
probably depends upon the intervals which elapse before the air dis- 
appears from the tympanic cavity. The amount of hearing depends 
upon the quantity of air in the tympanum. Sometimes the patient 
has to be loudly spoken to close to the ear ; at others a distinct 
voice is heard at the distance of two or three yards. There is fre- 
quently complaint of a sensation of weight or pressure in the ears, 
which often e:(tends to the head, when heaviness and great depres- 
sion of spirits are experienced. The latter symptom is very marked 
at times, but entirely vanishes with the removal of the obstruction. 

It possibly may originate from the pressure exerted upon the 
contents of the labyrinth by the forcing inwards of the membrana 
tympani and ossicles. A peculiar symptom sometimes met with in 
this affection, and for which I am unable to account, is the improve- 
ment which takes place during the temporary position of the head 
on a pillow, or even if it be turned round and kept looking back- 
wards. Irritation is often complained of in the external meatus > 
sometimes the dermis of the meatus becomes much congested, and 
eventually pours out a discharge ; and where it happens that the ir- 
ritation is still greater, a polypus forms, and there is a large quan- 
tity of mucus secreted. When a patient presents himself for advice, 



THE DISEASES OP THE EAR. 



with obBtruction of the Eustachinn tube coexisting with poljpiB « 
the sympathetic discharge from the meatus, unloBs the case be most 
carefully examined the real ilisease is apt to be overlooked, and con- 
sidered to be an affection of the meatus only. 

On ingpecting the rncmhrann fi/ntpa»i, it will be found very c 
cave, of a dull leaden hue, and its surface of uii unnatural, glassj 
aspect, the triangular spot being larger than natural. Somotimet 
the membrana tympani is so much drawn inwards as to approach 
the stapes, which is distinctly discernible through it ; in other cases, 
the membrana tympani is somewhat opaque, and its outer surfaoe 
uneven and irregular. 

Tiie crphration of the Eustachian tube. — The method of doingf 
this is so important to a thorough examination, as to require to tx 
treated in detail. In a paper read before the Medico-Chirurgieal 
Society in 1853, I pointed out a simple mode of ascertaininf 
whether the Eustachian tube' was pervious, and one which, as I 
general rule, is successful, without having recourse to the catheter.^ 
It has already been shown, that during the act of deglutition, wiU( 
the mouth and nose closed, a small quantity of air is passed through 
the Eustachian tubes into the tympanic cavities; a process that il 
attended with a sensation of fulness in the ears. The entrance of 
air into the tympanum can be distinctly heard by means of a 
elastic tube about eighteen inches long, each end of which is tipped 
with ivory or ebony ; an instrument which I have named the Ot<K 
ecope. One end of it is to be inserted into the ear of the patient, 
and the other into that of the medical man, who must take care 
that no portion of the tube touches any neighboring body. When 
the patient swallows a little saliva, the mouth and nose being closed^, 
if the Eustachian tube be pervious, at the moment that he feels K 
sensation of fulness in the ear, the surgeon will hear most distinctlj 
a faint crackling sound, produced apparently by a slight moTement 
of the membrana tympani. This crackling sound is that moat 
usually heard ; but in some instances where the mucous membrana 
of the tympanum is thick, a gentle flapping sound will be detected 
in its place. If in a case of suspected obstruction of the Eustar^ 
chian tube, the otoscope fail to reveal any sound during the act o( 
deglutition ; if no sound be heard when the patient makes a foroibU^i 
attempt at expiration with mouth and nose tightly closed; and i£ 
the history of the case, the symptoms and appearances, agree wit!| 
those already laid down as appertaining to obstruction of the Eu8t»- 



THE EUSTACHIAN TUBE. 



221 



chian tube, I thiak tlic surgeon \a justified in affirmiDg that the 
tube is obstructed, and has do need to resort to the use of the 
Eustachian catheter. Doubtless, in many cases, a person is unable 




The Otonape. 



to force air into the tyrapanum, although the pervious condition of 
the Eustachian tube is shown by the test of the otoscope, and this 
may depend upon a peculiar arrangement of the lips of the tube 
which causes them to be pressed together by the compressed air. 
There are other Ciises also where the tube may be proved to be 
pervious by the patient forcing air into it during un attempt at 
expiration, although the act of deglutition with closed nostrils does 
not call forth any sound appreciable by the otoscope ; but it is rare 
indeed for a pervious tube to resist both of these tests. I Imve, 
howevi^r, met with such cases; but, os their history, appearances, 
and symptoms have concurred in showing that no obstruction of 
the tube existed, it has not appeared necessary to introduce the 
catheter. In certain cases the membrana tympani may be seen to 
move during an attempt at expiration, even though no sound could" 
be lieard ; the patient, therefore, should always be asked whether 
he perceives any sensation in the ears during the above-named 
processes. 

Is the Eustachian catheter then useless as a means of diagnosis ? 
Notwithstanding its frequent use by surgeons in Germany and in 
France, I am disposed to think so. By paying attention to the 
points Just laid down, it is my opinion that a case of obstruction of 
the Eustachian tube can always be diagnosed without the aid of the 



222 THB DISEASES OF THE BAB. 

catheter. Respecting its ase as a, remedial agent, I ^hsU speak 
hereafter. 

That the cause of the obstruction of the Eustachian tube at its 
faucial orifice is the thickening of the mucous membrane, is proved 




The Surgton using the Otoscope. 



by actual dissection, hy the coexistent thiclcGning of the mncoiis 
membrane in other parts of the fauces, and by the results of the 
remedial measures adopted for its relief. An opinion formerly ob- 
tained a certain degree of credence in the medical profession, that 
enlarged tonsils frequently press upon and close the Eustachian 
tubes. There can be no doubt this opinion is erroneous. To con- 
vince himself that it is so, the surgeon has only to make an ex- 
amination of the relative position of the tonsil and of the trumpet- 
shaped extremity of the tube ; when he will find the tonsil situated 
from an inch and a quarter to an inch and a half below the tube, and 
placed between the palato-glossus and palato-pharyngeus muscles, 
the latter muscle entirely separating the tonsil from tho tube : he 
will also find tho Eustachian tube close to the base of the slcull, 
against the basilar process of the occipital bone, and surrounded by 
the tensor and levator palati muscles, the function of which is, as 
already shown, to open the tube. Repeated examinations have con- 
vinced me that even should the tonsil enlarge to its greatest possible 



THE EUSTACHIAN TUBE. 

known extent, it never reaches tbe Eustachian tube ; for, together 
with the enlargement of the tousils, the palato-pharyngeus muscle 
also hypertrophies, and effectually separates the two organs. Nay, 
further, in the cases seen by me, where the tonails have been tbe 
largest, there has been no deafness ; a fact which must also have 
been observed by other medical men. Often, in a case of obstructed 
Eustachian tube in one ear, the tonsil has been comparatively small 
on tbe deaf side ; while on the opposite side, where there has been 
no deafness, the tonsil has been large. Thore is no doubt that ob- 
struction from hypertrophy of the mucous membrane of the faucial 
orifice of the Eustachian tube may coexist with enlarged tonsils ; hut 
the mere coexistence of two affections must not be confounded with 
cause and effect. 



TREATMENT OP OBSTRCCTtON OP THR.FAUOIAL ORIFICE OP THE 
BUSTACniAN TDBB BY TEICKBKIiD MUCOUS UBMBRANE. 



Cases of this disease, when uncomplicated with any affection of 
the tympanum, ordinarily yield to the use of general remedies and 
applications to the fauces, without touching the outer ear. The 
object to be aimed at Is the reduction of the congestion and hyper- 
trophy of the mucous membrane surrounding the orifice of the tube, 
so as to allow the muscles again to exorcise their function of opening 
it ; and for this purpose considerable patience and persevorance are, 
doubtless, frei]uently required ; since in many strumons persons, 
especially if young, the tendency to congestion and thickening is 
very great. 

General Jtemcdies. — The most efficient of these are abundant and 
active exercise in the open air, and warm clothing. Flannel should 
be worn next to the skin. In youths tbe flannel jacket, extending 
from the neck to the ribs, may not only be worn, but, in cold weather, 
in front, where the chest is exposed, a small additional piece of flan- 
nel may be worn suspended from the neck. The throat should not 
be wrapped up with handkerchiefs, comforters, boos, &c., as they 
only servo to weaken it, by keeping it warm for a certain time, and 
then, on their removal, leaving it exposed frequently to a colder air 
within doors than had prevailed without, thus bringing on relaxation 
of the mucous membrane. Where a single tie-handkerchief is worn 
within doors, no addition is needed on going out; and where in 



224 



THE DISEASES 



children the throat is left bare within the house, a small silk hand- 
kerchief, hostly tied, ia all that is required without. I have been 
thua particular on these points, because experience frequentlj con- 
vinces me of their great importance. 

The surface of the body should be daily sponged or rubbed with a 
coarse towel that has been di]iped in cold water, and then wrung 
out. Aa the children who suffer from the affection under conside- 
ration have usually a languid circulation and deficient nervoua 
energy, the towel bath appears to be a remedy advantageous in 
both respects. The towel should be very coarse, and only one part 
of the body should be rubbed at a time. The skin, especially that 
of the neck, throat, and spine, should be brought to a ruddy glow. 
This bath may be used either in the morning or the evening, but 
once daily ia sufficient. If the patient be so very delicate thai he 
cannot well bear the alight shock produced by the cold towel, tepid 
water may be used. In addition to this bath, indeed to supersede 
it, especially in youths of from fourteen to sixteen, by whom it u 
not likely to be carried out effectually, the tepid or cold plunge-bath 
may be resorted to. When it can be practised, sea-bathing should 
not be neglected; but in all caaes of entire immersion it is advisable 
to wear an oil-akin cap, to keep the head dry : and this, not because 
the application of water to the bead ia objectionable, but bccausS' 
there is ao great a difficiilly in perfectly drying the hair, and thd 
slow evaporation from it ia often decidedly injurious. Plunging 
into a fre.sli- water river in warm weather ia not prejudicial. In the 
treatment of the casca in question, too much stress cannot be lud 
upon the necessity of exerciae, bracing air, and cold bathing. I 
have known them to overcome the most obstinate cases of obstrtio- 
tion of the faucial orifice of the Eustachian tubes, where all local' 
remedies and medicines had given slight or only temporary rclic£i 
Care should also be taken as to the diet of the patient: paetry, 
sweets, fat, &c., should be avoided; vegetables may be sparingly^ 
partaken of; and the principal food should be bread, especially thi 
containing the bran, meat, and light puddings, as rice, sago, hoA 
Children should not be overworked in their studies, should relii 
early, and their sleeping- rooms should be airy and well ventilated 
(it is a good plan to leave the bedroom door ajar during the whols 
of the night); and, above all, it is important that the head should 
be kept above the bedclothes, 

To overcome the very prevalent habit of breathing through the 



i 



THE EUSTACeiAN TUBE. ti^O 

mouth, whereby the cold air keeps up a constant irritation of tlie 
faucial mucous membrane, the patient should be directed to sit down 
quietly for a certain time daily, and practise the habit of na^al 
respiration. Although it may at first seem difficult, the mucous 
membrane of the nose soon yields, and the air passes freely.' 

Medicints. — All medicines that impart tone to the system, may 
in turn be resorted to. Cod-liver oil, iron in various forms, iodide 
of iron, iodide of potassium, creasote, and the mineral acids and 
Tegetable hitters, will be found useful. 

Local Treatment. — The moat efficient local application ia undoubt- 
edly the nitrate of silver, which may generally be used in a solid 
form. Messrs. Weiss have made for me a caustic holder, the end 
of which is capable of being turned at such an angle, that the 
caustic may be passed behind the soft palate, and applied to the 
mucous membrane of the orifice of the tube, as well as to that of 
the fauces. Should the tonsils be enlarged, the solid nitrate of 
silver may he rubbed over their surface, and over that of the faucial 
mueons membrane, about once a week ; and it should produce con- 
siderable irritation and a copioiis flow of mucus. Stimulating 
gargles are also to be used; those combining acids and astringents 
are of service. Iced or cold water is often beneficial ; and in order 
to insure the application of the cold water to the orifices of the 
tubes, as well as to improve the condition of the mucous membrane 
of the nares, the water may be drawn up through the nose, and 
passed out by the mouth. When there is much congestion of the 
fancial mucous membrane, a leech or two, a stimulating liniment, or 
a vesicating paper, may be applied over the region of the tonsils. 

The itse of the Eustachian catheter. — It was, and is even now, 
the custom of some surgeons to pass the Eustachian catheter re- 
peatedly in cases of obstruction of the Eustachian tube. Now, 
what is the effect of this procedure ? If the mucous membrane be 
not much thickened, air is blown into the tympanic cavity, and the 
power of hearing is improved. As soon, however, as the catheter 
is withdrawn, the tube again closes, and its muscles have not the 
power to reopen it ; while the air which has been forced into the 
cavity soon disappears, and the deafness returns. The patient 
again seeks relief from the same process and with the same result ; 



mott iffioicnt DktDttl "rMpi»tor." 



226 



THE DISEASES OF THE 






for if the mucous membrane is allowed to remain in ita cxiating 
state, no permanent relief is to be hoped for ; on the contrary, the 
repeated use of the catheter tends rather to increase than dimini&h 
the congealed state of the membrane. Under certain circum- 
stances, however, the EuBtachiRO catheter is of great value. The 
judicious course respecting it, is to use the above-named plans for 
the purpose of reducing the hypertrophy of the mucous membrane, 
which will, in the majority of cases, effect the cure of the disease. 
If, after pursuing these measures for ten days or a fortnight, no 
amelioration ensues, the Eustachian catheter maybe introduced and 
air blown through the tube into the tympanum ; an operation which 
may at times possibly facilitate a cure by the removal of mncua 
from the tube, or by liberating the lips of the faucial orifice. Seve- 
ral days, however, should elapse before the operation, if required, la 
repeated, and this will seldom bo the case. 

The mode of applying the Eustachian catheter. — It has been 
already stated that the orifice of the Eustachian tube is posterior 
and external to the posterior aperture of the inferior nasal meatuK. 
The catheter used by me is not quite so large as an ordinary crow- 
qnill ; and as the outer part of the Eustachian tube is oval, it has 
been recently suggested by me that the extremity of the catheter 
should be of the same sho.pe. The end of the catheter taken hold 
of by the surgeon should be rather larger than that which is to 
enter the tube, in order that the end of the explorer, or the noisle 
of a syringe, may be fixed in it. This end having a ring on the 
side opposite to the concavity of the curved end, is to he taken in 
the right hand of the surgeon, the patient being seated in the chair 
before him, and then the instrument, with the point downwards, is 
to he made to glide backwards, by the side of the septum im$i, until 
the curved end reaches the cavity of the fauces, when it is to be 
pressed backwards against the mucous membrane of the posterior 
part of the fauces. It is ne.\t to be drawn slightly forwards, and 
then rotated outwards, so that the extremity may turn upwards and 
catch the orifice of the Eustachian tube, which can be distinctly felt, 
and will prevent the further rotation of the instrument. The cathe- 
ter is now to be pressed slightly outwards and backwards, when the 
Burgeon will feel it to be embraced by the tube. For the purpose 
of securing the instrument, a frontlet bandage, with a pair of for- 
ceps attached, has been used ; but it may he dispensed with in all 
ordinary cases : for the surgeon has only to transfer the catheter to 




THE EUSTACHIAN 



227 



his left band, anil wIiilc holding it lightly, so as not to cause pain to 
the patient (as the use of the frontlet invariably does), insert into 
the diUteil end of that instrument the small end of the explorer or 
of the syringe. The explorer, which in my hands has entirely super- 




Beded the use of the air-press, consists of an elastic tube, about 
eighteeen inches long, one end of which has a flat mouth-piece of 
ivory, with one or two deep incisions npon it, to enable it to be 
easily held by the incisor teeth of the operator, while the other end 
has a small portion of steel tubing attached to it, which fits accu- 
rately into the further end of the catheter. 

When the catheter has been properly fixed, as directed in the 
tube, and held there by the left hand of the surgeon, one end of the 
explorer is to be placed in bis mouth, and the other in the catheter, 
and held there also by the loft hand. With his right hand, thus 
left at liberty, the surgeon is now to take the otoncope and introduce 
one end of it into the ear of the patient, who may hold it there, the 
other end being held by the surgeon in his own ear ; or the tube 
may be made so light as to remain there without being held, leaving 
the operator's right hand still free. 

The medical man next proceeds to blow air gently through the 
explorer, at the same time that he listens through the otoscope to 
ascertain whether the air enters the ear, and if it does, what is the 
peculiar sound it produces. When the tympanum is unobstructed 
by mucus, the air is heard to pass in a stream against the inner 
surface of the membrana tympani, but when mueua is present, a 
peculiar gurgling is heard ; and if the raucous membrane itself is 
thickened, a peculiar squeak or bubbling is also perceptible. It is 



228 



UES OF lUE EAR. 



not advisable to blow with force into the ear, but rather to make a 
few gentle successive puffa, attentively listening during each, to 
detect the kind of Bound that may be heard in the tjmp&nDnu , 




Tha Sargton luiiig ths Eastiwhian Cutheler snd tha Explorer. 

Sometimes no air enters, the mucous membrane being too thick to 
allow it to pass ; and, under such circumstances, it is unwise to 
attempt to force the air into the tympanum. Great mischief has, 
indeed, frequently resulted from such a proceeding; the mucous 
membrane having been lacerated, and tbc air been driven into the ■ 
submucous tissue, causing extensive emphysema. Nay, still mora j 
serious results have occurred, the patient having been killed in- 
stantaneously, perhaps through the effusion of air through the I 
fenestra rotunda (the membrane ha\-ing been lacerated) into the [ 
labyrinth, and the shock upon the nervous system causing instant j 
death. Nor need it be a source of surprise that the effusion of i«r 
into the labyrinth should prove fatal, since even the forcible disten- 
sion of the tympanum, while blowing the nose frequently, produces | 
giddiness by pressure upon the labyrinth. 

The excision of the tonsils. — On the supposition that the tonsil, J 
when enlarged, pressed against and closed the faucial orifice of the I 
Eustachian tube, the operation for excision, or partial excision, of I 
the tonsils, has long been practised for the relief of deafness. Al- j 



THE EUSTACHIAN TUBE. Z'2i) 

though, as already shown, the tonsil, however hypertrophied, cannot 
cause occlusion of the Eustachian tube, still the removal of a portion, 
in ca^es where it is muek enlarged, is sometimes of Bervice by ditnin- 
iahing the congestion of the mucous membrane at the orifice of the 
tube ; and it perhaps also operates beneficially by allowing the 
musclca of the tube to act more freely. This operation is, however, 
very rarely required ; and the best rule to follow is never to excise 
a portion of the tonsil, which appears to have important functions, 
independent of the fauces, unless it evidently interferes with the 
general health of the patient, or unless the obstruction of the 
Eustachian tube resists the other measures already indicated. 



CASES OF TUE OBSTRCCTION OF THE EUSTACULAN TL'BE BY THIOK- 
BNBD MUCODfi MKMBBANE, AT ITS PAUCrAL ORIFICE. 



Ca»e I. — Master M. J., agod 15, was brought to consult me, on 
December 4, 1852, on account of a very serious diminution of the 
hearing power, in both cars. He was in tolerable health, but pale. 
About a year previously, after suffering from a bad cold, ho became 
dull of hearing, and since then has been able to hear only when 
spoken to in a loud voice, within the distance of a yard or two. 
Occasionally he has felt a sensation as of something bursting in the 
ears, which has been followed by slight, but only temporary relief. 
Upon examination^ the mucous, membrane of the fauces was found 
very thick and red, and both tonsils greatly enlarged. The right 
ear. — ^Watch heard only when in contact with the ear ; the membrana 
tympani being opaque, of a leaden hue, and more concave externally 
than natunil, while, instead of the usual triangular bright spot, two 
height spots were perceptible, showing that the membrane was de- 
prived of its ordinary evenness of surface. Upon listening with the 
otoacope while the patient swallowed, the mouth and nose being 
closed, and while be tried to force air into the tympanum, no sound 
was heard. The left ear was in a very similar state to the right ; 
the watch, however, could be heard at a distance of two inches from 
the ear. Feeling assured from the history of the case, the symp- 
toms, the condition of the throat, tho appearances of the oar, and 
the negative results following the use of the otoscope, that the 
Eustachian tube was closed at the faucial orifice, especially as there 
was no indication of disease in the tympanum, which might lead to 



SEASES OF THE EAB. 



the sufiposition of tbe tympanic orifice being affected, I did not itse 
the Eustachian catheter, but proceeded ut once to apply a. solution 
of nitrate of silver to the mucous membrane of the fauces, and to the 
orificca of the Eustauhian tubes. Three grains of the sulphate of 
iron were given daily in combination with ten grains of sulphate of 
magnesia, and slight counter-irritation was kept up over the regicm 
of the tonaila. As a remedial measure, the catheter was not resorted 
to, as it was evident that the hypertrophy of the mucous membrane 
had slowly come on, and it was not probable that it could be other- 
wise than slowly improved. The first effect of the treatment hbss 
slight improvement of tlie hearing, although the tube remamed 
impervious ; an improvement which probably depended upon the 
diminution of the congestion in the mucous membrane of the tym- 
panum. By the end of January, the hearing power of the right 
ear had greatly improved ; and in the middle of February, the air 
passed freely through tlte Eustacliian tubes during the act of deglu- 
tition, and the patient heard quite well again. 

Case II. Obxtruction at the faucial orifice for two montht. — ^W. 
W., Esq., aged 52, being strong and in good health, consulted m« 
on July 26, 1853, He stated that two months previously, after ft 
bad cold, he became alowly deaf in both ears, so as to require per- 
sons to speak loudly to him within the distance of a yard. On tbe 
24th, after yawning, he suddenly experienced a crack in the left 
ear, and as suddenly heard well ; but this improvement only lasted 
for a day, and then the deafness slowly returned. He has hod three 
similar attacks during the last ten years, but In about a month's 
time the hearing usually returned after a cracking sound in the 
ears. At times, on throwing the head back, he has found the hear- 
ing power in the right ear much improved. On examination, the 
mucous membrane of tbe fauces was red and hypertrophied. 

Right ear, — Hearing distance three inches ; the meatus w&a red 
and hypertrophied, the membrana tympani more concave than nata- 
ral, its surface uneven, and instead of the single triangular bright 
spot, there were two smaller spota. 

Eustachian tube. — The otoscope did not detect any air entering 
the tympanic cavity during the process of deglutition, or upon 
attempt at a forcible expiration with closed nostrils. 

Left ear. — Watch heard only when in contact with the ear ; the 
membrana tympani was in a similar state to that of the right i 





THE EUSTA 



231 



and the long process of the incus could be seen through it. The 
Eustachian tube was impervious. 

By the use of stimulating gargles and a liniment over the ears 
and throat, the patient entirely recovered in the course of a fort- 
night. 

Case III. Obstruction of the faueial orifice : catarrh from meatue: 
tomiU very large: cure without excision. — Master B., aged IG, was 
brought to consult me in August, 1850. His general health was 
not very good, and he was subject to glandular enlargements. 

Mistory. — The right ear has always been slightly dull, and for 
two or three years it has been worse. The left ear lately has also 
become so dull, that he requires to be spoken to distinctly within 
the distance of a yard from the head. Has had several attacks of 
earaehe ; after which, and also after a cold, the deafness is increased. 
Has had discharge from each ear on several occasions, and complains 
of a singing in them. When asleep he makes a loud snoring sound, 
and he always breathes through the nose. At times has had a 
cracking sound in the ears, which has been followed by a tempo- 
rary improvement. On examination, the tonsils were found to be 
so greatly enlarged as nearly to touch the median line, while the 
.mucous membrane of the fauces and of the nose was much thicker 
than natural, 

Jtight ear. — Hearing distance half an inch ; membrana tympani 
concave ; bright spot somewhat dull. Eustachian tube impervious. 

Left ear. — Hearing distance two inches; the bright spot of the 
membrana tympani subdivided. Eustachian tube obstructed. 

As the tonsils in this case were so much larger than natural, and 
as they apparently interfered with the respiration of the patient, 
and perhaps with his health, it was thought that the removal of a 
portion of one or both might be attended with benefit : but the pa- 
tient's friends so strongly objected to the operation that it was not 
performed. The treatment consisted in the application of solid 
nitrate of silver to the fauces; in the use of an astringent gargle 
with counter-irritants over the ears and throat; in the administra- 
tion of tonic medicines; and in careful diet, with abundant exercise 
in the open air. On August 2l8t, a crack took place in the left ear, 
when he heard perfectly for a short time. After this date, a suc- 
cession of cracks was heard in each ear, and at last the hearing 
power entirely returned and remained perfect, except during a cold, 
the effects of which, however, soon disappeared. 



DIBEABES OF THE E 4 R. 

Case IV. Obstruction from the mucous viembrane of the _fauee$; 
polypus in meatus externug ; rpmoval by operation; cure. — II. W., 
Ebcj,, aged 19, was sent to me by Mr. White Cooper, in Febriianr, 
1854, on accoHiit of a considerable diminution of the power of hexr- 
ing, and of a discharge from the right ear. Hla health was not very 
good, and he was subject to enlarged cerTical glands. The history 
of the case was, that about two years ago be found himself becoming 
gradually dull of hearing. After this dulness had rema.ined some 
months, accompanied by a feeling of fulness in the ears, a discharge 
took place from the right ear, tbe quantity of which has lately con- 
siderably increased. On examination, the mucous membrane of tlifl 
fauces was observed to be red and thick. 

Bight ear. — The watch beard only when in contact ; a raspberry 
polypus, the size of a small pea, was seen to fill the meatus, close to 
the membrana tympani. 

Left ear. — Hearing diataneo six inches ; membrana tympani 
opaque, and calcareous in parts. Each Eustachian tube was itnper- 
vious to air. The treatjncnt consisted in the removal of the polypns 
by means of the lever-ring forceps. The membrana tympani wu 
then observed to be white. Astringent and acid gargles were used; 
slight counter-irritation was kept np over the ears and tbe region ot 
the fauces; tonics were administered; and daily sponging with cold 
water was enjoined. In the course of a week a crack took place in 
the right ear, followed by idimediate great improvement of the 
hearing ; this was succeeded by a crack in the left ear, and a perfect 
restoration. The discharge also wholly disappeared. On seeing 
this patient several months afterwards, I found his hearing perfect, 
and there had been no return of the discharge. 

I have said that tbe use of tbe Eustachian catheter is rarely re- 
quired, because the state of the mucous membrane generally so much 
improves by means of the other remedies. In the following case, 
however, where there was an additional cause of impediment besidee 
the thickened mucous membrane, the catheter was used with advan- 
tage. 

CaseV. Impervious condition of the tube from hypertrophy of the 
mucous viembrane at the faucial orifice- ; fissure of the palate ; ca- 
theter used with advantage. — Dr. P., a medical man, aged 43, con- 
sulted me in 1853, on account of deafness. 

History. — Several years previously be had a disease of the palate, 
which terminated in the loss of a considerable portion of the palatal 



THE El! ST A 



eiAN TDBE. 



233 



processes of the superior maxillary and palatal bones, anil caused a 
large fissure. During the last two or three years he has suffered 
from attacks of deafness during a cold, which, after continuing for 
some weeks, have disappeared. On eraviination, the mucous mem- 
brane of the fauces was found to be red and much thicker than natu- 
ral. Towards the posterior part of the palate was a large fissure, 
exposing the trumpet-shaped extremity of the Eustachian tube; the 
mucous membrane of which was much swollen. Each membrana 
tympani was of a leaden hue and very concave ; and there was an 
appearance of redness beyond each, as if the mucous membrane were 
congested. The patient had to bo spoken to distinctly within the 
distance of a yard. The Eustachian tubes were impervious. 

Treatment. — A solution of nitrate of silver (3ij @ 3j) was applied 
to the mucous membrane of the fauces and to the orifices of the 
tubes; an astringent gargle was ordered, and gentle counter-irrita- 
tion over the throat. This treatment produced a slight improve- 
ment ; but as the deafness soon returned, as the patient was espe- 
cially anxious to hear, and as it appeared probable that the muscles 
of the tube were partially disabled from performing their function, I 
passed the Eustachian catheter, and, by means of the explorer, blew 
air into the tympanic cavities. The good effect was instantaneous, 
and the patient heard well. The improvement, however, lasted for 
only about twelve hours, when the deafness gradually returned. At 
the desire of the patient I passed the catheter on several occasions, 
while other treatment was being followed. After each operation the 
hearing improved for about the same space of time ; ultimately the 
condition of the mucous membrane was so much improved as to allow 
the muscles to open the tubes, and a cure resulted. 

In some cases after the Eustachian tube has been obstructed for 
a long time, the patient may almost wholly lose the power of hear- 
ing. These cases, as will be seen by the following instance, are by 
no means to be despaired of. 

Cate VI. Obstruction by thickened mucous membrane of the 
faucial orifice ; duration of many years ; great and prolonged hard- 
jieti of hearing; cure. — Miss J. A. O., aged 12, was brought tome 
from Manchester, on the 16th April, 1853. She was strong, but 
rather pale. The history of the deafness was, that during several 
years she had been dull of hearing during a cold; on the disap- 
pearance of which, the power of hearing partially returned, so that 
she could hear without much difficulty. For some months the deaf- 



8E8 OF TUE 



aeas has been eo much ivorse, that she cannot tear unlesa spokn 
to in a loud voice into the left ear, the right heilig useless. On 
examintitioTi, the mucous memhrane of the fauces was found to he 
red, thick, and spongy, hut the tonsik were not larger than natural; 
The mucous memhrane of the nose was very thick and red ; and 
respiration was usually carried on hy means of the mouth. 

Might ear. — Watch heard on pressure, but indistinctly; membrana 
tympsni concave, surface uneven ; and on that surface three irre- 
gular-shaped bright spots were seen. Eustachian tube iupernona. 

Left ear. — Watch lieard when pressed ; membrana tympani and 
Eustachian tube the same as in the opposite car. 

Treatment. — The solid nitrate of silver was directed to be applied 
to the mucous membrane of the fauces once a week; counter-irritation 
over the ears, and a leech or two at times over the region of the 
fauces; the one-thirtieth of a grain of the bichloride of mercury 
twice daily, and a warm hath once a week : occasionally an emetic 
was also given. She returned to Manchester, and on the 28th of 
May her father wrote to me, saying that she was " so much better 
that she can keep up a conversation across the table." The child 
had a relapse in the following January, but a repetition of the 
treatment again restored her to perfect hearing. 

It is not, however, only in long-standing cases of obstruction of 
the Eustachian tube that the deafness is very considerable ; in weak 
persons almost total deafness may come on in a few hours. Awelk 
marked case of the kind ha8 occurred to me while writing f" 
present chapter. 

Case VII, Sudden obatruetion of each Eustachian tube from con- 
gestion and thickening of the miteoitg memhrane of the fauces, pro- 
ducing total def^fnesi in a few hours ; cMrc.-— Dr. B,, on the 24th 
January, 1S55, called to ask me to see his wife, of whom he gaw 
the following history. 

For several months she has been much out of health, and confined 
to her room ; but has never suffered from any deafness or disease of 
the ear. On the night of the 20tb instant she awoke, complaining 
of a loud singing in her ears ; and when spoken to, it was found 
that she was so deaf as not to he able to comprehend what was said, 
although addressed very loudly. If possible, this deafness increased, 
so that on the 22d no sounds were heard, and all communication had 
to take place in writing. On examination, on the 24(h, I found 
that the deafness was complete; each membrana tympani was very 



THE EUBTACniAN TUBE 



235 



concave and dull ; tlie mucous membrane of the fauces was very red 
and thick, the tonsils and uvuln much swollen. Each Eustachian 
tube was impervious. Upon inquiry I learnt that accidentally a 
part of the window had been left open during the night. The 
treatment recommended was the application of the solid nitrate of 
silver to the fauces and the orificeB of the Eustachian tubes. This 
was done freely about eleven o'clock on the 2t>lh. Dr. B. returned 
home about two hours after, and found the bearing so improved that 
he carried on a conversation with his wife in a loud voice. 

I might add to the above a large number of cases in which the 
treatment was quite successful, but will merely give the leading 
particulars of another, 

Ca»e VIII. — H. L., Esq., aged 28, consulted me on June 25, 
1853. Has suffered for several months from sore throat, conse- 
quent upon an attack of secondary syphilis: for two months has 
complained of deafness in both ear», so as not to bear any except 
a loud voice. The deafness is accompanied by constant singing, 
which is increased when the bead is on the pillow, and it varies 
much. On one occasion, after gargling the throat, heard much 
better with the right ear for twelve hours. On examination of the 
right ear, the hearing distance was half an inch ; the memhrana 
tympani was opaque and of a leaden hue; the surface shone, but 
the bright spot was nearer the circumference of the membrane 
than natural. The Eustachian tube impervious. The left ear was 
in the same condition as the right. The treatment pursued was 
the use of the nitrate of silver to the fauces, and the administra- 
tion of steel wine. On July 2d he told me that three or four days 
previously be heard quite well in the morning, and the improve- 
ment lasted for two days, since which he bus been gradually getting 
deaf again. By perseverance in the treatment for a month he 
perfectly recovered. 



(fi.) OBSTRDOTIOM OF THE EUSTACHIAN TUBE AT ITS FAUCIAL 
ORItlCE FROM RELAXED UUCOUS MEMBRANE. 



This affection is far from being so frequently met with as obstruc- 
tion arising from thickened mucous membraDe. In many symptoms 
the two affections greatly assimilate, but they also present certain 
decided differences. Obstruction from relaxed mucous membrane 



236 THE DISEASES OF THE EAR. 

occurs less frequently in childfen or in persons subject to glandolar 
enlargements, than in persons who have no thickening, but simply 
a relaxed state of the mucous membrane of the fauces. The 
physical cause of the obstruction appears to bo a relaxed condition 
of the mucous membrane covering the faucial orifice of the tube, 
80 that its muscles are unable lo separate the lips sufficiently to 
admit the air. The predisposing cause is generally some debili- 
tating influence, as over-work, keeping late hours, indigestion, &e. 
The exciting cituse is often a cold. There is usually no history of 
any previous affection of the ears, the deafness comiug on slowly, 
and gradually increasing until the patient is unable to hear ordi- 
nary conversation, and requires to be spoken to in a loud voice. 
Sometimes the patient improves for a short time, and then the 
deafness returns; but frequently the hearing is better when the 
head is placed in a recumbent position, or when the face is turned 
and looks backwards. There is often a feeling of weight in the 
ears, with a singing sound, and at times a sensation of confusion 
in the head. On examination, the patient generally looks pale 
and out of tone ; the pulse is weak ; the mucous membrane of tbs 
fauces is cither relaxed and red, the bloodvessels being large and 
presenting long streaks; and the uvula is either hanging down, bo 
as to touch the dorsum of the tongue, or it is of a much paler 
color than natural from being deprived of its due supply of blood. 
The membrana tympani is much more concave than natural, fre- 
quently of a leaden hue, its surface being glassy. Not unfrequcntly 
the long process of the incus is seen through it. Upon exploration 
with the otoscope, the Eustachian tube is found to be impervious. 
The treatment differs somewhat from that of cases of obstruction 
from thickened mucous membrane. Instead of nitrate of silver, 
stimulating gargles are to be used — one composed of whiskey ia 
often very serviceable ; tonic medicine and stimulants are to b6 
administered, generous diet, rest from work, country air, and 
abundant out-door exercise, should also be prescribed. Similar 
reasons to those which induce me not to use ordinarily the Eusta- 
chian catheter in cases of obstruction from thick mucous membrane, 
have prevented my resorting to it in the cases under consideration. 
Its use could not, of course, diminish the cause of obstruction, op 
facilitate the progress of the treatment ; and unless the patient, 
from some particular circumstances, was desirous to hear v^' 




THE ETJSTACniAN TUBE. 



23T 



during a few boure, the introduction of this instrument should be 
avoided, A cure is always to be effected without it. 

Cage I. Obstruction of the left tube from relaxed condition of the 
mucous membrane; constant beating sound. — J. R. H., Esq., a 
surgeon, aged 48, conBulted ine on December 15, 1823. The 
hUtory was, that about sis weeks previously be found himself deaf 
in the left ear ; he felt no pain, but there was a constant sensation 
of beating in the ear, and a weight on that side of the bead, which 
caused extreme discomfort. He is subject to a relaxed throat. 
On examination, the mucous membrane of the faueea was observed 
to be relaxed, though not thicker than natural ; the meatus ex- 
ternus of the left ear was dry and smooth, and did not contain 
any cerumen ; the membrana tympani was very concave and some- 
what opaque. The processus brevis stood out very prominently ; 
but the manubrium was so much drawn inwards that it could 
scarcely be seen. The otoscope showed the Eustachian tube to be 
impervious. The watch heard only in contact with the ear. The 
right ear perfectly natural. 

Treatment. — A whiskey gargle was ordered, and a mustard 
plaster to be placed on the region of the fauces ; the outside of the 
throat to be rubbed with a coarse towel dipped in cold water ; simple 
food, as much rest and as little "night-work" as possible. 

December 24th. — A crack took place in the ear, and the hearing 
became perfect for a few minutes, but again became gradually dull. 
The treatment was persevered in, and on the 7th January, 1854, 
the gentleman wrote, " I am quite well ; the air passes into the ear 
perfectly well." All the unpleasant symptoms had subsided. 

Case II. Obstruction in each tube for ten days after an attack of 
bronchitis. — S. S., Esq., aged 51, an architect, was brought to me 
on June 24, 1853. 

History. — He has had a bad cougb and bronchial afiection for a 
month, which came on after having been considerably over-worked. 
Ten days ago deafness came on slowly in both ears, and has re- 
mained till now ; so that he has to be spoken to in an elevated tone 
within a yard. He hears much better in the morning when reclin- 
ing in bed. Has frequently tested his hearing by means of his 
watch, and the result is, that when lying down he can hear it at a 
distance of two feet with either ear ; but after being in the erect 
posture for a minute or two the deafness returns, and he can hear 
the watch only at two inches from the ears. He has now and then 



SE8 OF THE BAR. 



had a Blight crack in each ear, folloired hy eoraewhat improTftd li 
iDg. Od examination, the pulse wa.s weak aud slow, the face pale 
and flabby, and the raueouB membrane of the fauces wna seen to he 
relaxed, with enlarged streaky vesaela ramifying in it. 

Right ear. — Watuh heard only when in contact with the ear; the 
surface of the membrana tympani was dull, had a dark leaden hoe, 
and the membrane was much more concave than natural, having two 
irregular-shaped bright spots in place of the single one ; the long 
process of the incua was seen through the membrana tympani, a&d 
appeared to be in contact with its inner surface ; the Eustachian 
tube was impervious. 

Left ear. — Similar to the right : hearing distance, a quarter of ai 
inch. 

The treatment consisted in the administration of tlie citrate of 
iron, followed by decoction of bark and sulphuric acid; the use of 
a tannin gargle and gentle external counter-irritation. He wae also 
advised to sleep in the country, to work us little as possible, and to 
live generously. On July 2d there was a slight improvcmpnt, bnt 
as yet no free passage for the car through the tubes. On July 7th 
a suddcji and great improvement took place in the right ear, after 
blowing the nose. Hearing distance, six inches in the right, and a 
quarter of an inch in the left oar. Cracks now occurred in both 
eara from time to time, and were followed by great amelioratiOQ in 
the hearing. At the end of July he had perfectly recovered. 

Case III. Obstruction 'it the fitueial orifice from relaxed mue^Ui 
membrane for two tnonths after influenza. — Miss. T., aged 16, ■ 
brought to me on June 7th, 1S53. She was pale, with a weak puU^ 
and somewhat out of health, having had an attack of influenza for 
two months. Catamenia irregular. 

History. — When a child, was subject to dulncss of hearing during 
a cold, but recovered as soon lis the cold passed away. During the 
recent attack of influenza has been so dull of hearing as to requirft 
to he spoken to distinctly within the distance of a yard ; general 
conversation is not heard. Sometimes during an entire day hears 
rather better. Complains of a ticking noise in the ears. 

Kesults of examination: right ear. — Watch only heard on prea- 
Bure; membrana tympani, surface dull, concave; Eustachian tubt 
impervious. Left ear. — In the same state as the right. The n 
membrane of the fauces was rela.xed. 

Treatment. — Considering that the relaxed condition of the fkooii^ 




THE EUSTACHIAN TCDE. 239 

mucous membrane was dependent upon the state of the health, steel 
was adminiKterod, and plans for invigorating the system were recom- 
mended : gentle counter-irritation over the region of the fauces was 
also enjoined. 

Julj 13th. — Has had a " rumbling" sound in the ears, since 
which she has been better. Hearing distance, two inches. 

July 20th. — Well. Eustachian tubes pervious. 

Several additional cases might be related, but the three I have 
mentioned will be sufficient to illustrate the nature of the affection. 



(e.) OBSTBUCTIOS OF THE BUBTACHUN TUBE AT THE TYMPANIC 
ORIFICE FROM THICKENED MUCOUS MBMBKAKK. 

Inasmuch as one of the most common affections of the ear is in- 
flammation of the tympanic mucous membrane, it will he readily 
conceived that obstruction of the tympanic orifice of the Eustachian 
tube is likely to take place from the same cause. It is well known 
that the osseous portion of the Eustachian tube, which is about the 
size of an ordinary probe, is lined by an extremely thin mucous 
membrane, which, like that covering the osseous walls of the tym- 
panum, adheres firmly to the surface of the bone, and appears to 
act in the twofold capacity of a periosteum and mucous membrane; 
one of the reasons for its extreme tenuity being the fact that the 
bony part of the Eustachian tube forms part of the cavity with re- 
sonant walls. The whole of the mucous membrane of tlie Eusta- 
chian tube, excepting at the two extremities, is so surrounded by 
muscles and bone as to be little liable to become the seat 'of dis- 
ease. In making dissections, I have rarely found that it has been 
morbidly afiected ; indeed, in some cases of ulceration of the faucial 
mucous membrane in scarlet fever, accompanied by ulceration of 
the mucous membrane of the tympanum, the membrane lining the 
central portion of the tube has been found free from disease. It 
would thus appear that the commonly received opinion of the ex- 
tension of the disease, by direct continuity, from the fauces to the 
. tympanum, is not always correct ; and from observation of what 
occurs in other cases, there is no difficulty in conceiving the affections 
of the two parts to originate at the same time without any relation 
of cause and effect. It cannot be doubted that it is very fortunate 
the mucous membrane of the central part of the tube is so little 
liable to become thickened, since it would of course be very difficult 
to act upon it effectually. 



THE DISEASES OF TBB EAR. 



i 



The mucous membrane coyering the bone wbich forms the tyni*' 
panic aperture of the tube is, on the contrary, liahlo to congestjoa 
and hypertrophy, being, like the mucous membrane of the tympa- 
num, exposed to the influence of the cold air entering the roeBtus 
externus. Symptoms arising from this cause are usually present in 
the cases under consideration ; but there is generally in addition a 
great concavity of the membrcina tympani, loud noises in the ears^ 
and, upon examination, an impervious state of the Eustachian tube. 

The history of the two caaea differs in the fact, that in cases of 
I obstructed Eustachian tube, the deafness generally comes on rapidly, 
often disappears, and as rapidly reappears ; whereas in those arising 
from disease in the mucous membrane, the progress is usually sloir 
and regular. It must also be remembered, that in cases of obstruc- 
tion of the Eustachian tube at the tympanic orifice, thero U com- 
monly a history of previous attacks of inflammation in the tympanic 
mucous membrane, which is not often the case in instances of ob- 
struction at the faucial orifice : the membrana tympani also presents 
appearances indicative of inflammation having occurred in the tym- 
panic cavity. The most simple cases of obstruction of the Eusta- 
chian tube at the tympanic orifice are those following an ordinary 
cold, in which a sense of fulness is felt in the ears, often attend^ 
with noises, and with dulness of hearing — symptoms which last for 
a few days, and then ordinarily disappear with a sensation of some- 
thing bursting in the ear. 

In the treatment of these cases, all those measures should be re- 
sorted to which will be described aa serviceable in hypertrophy of. 
the mucous membrane of the tympanum. In addition, the oper&- 
tion of puncturing the membrana tympani is sometimes advisable. 



ON TUB OPERATION OF PUNCTURISa THE MEMBRANA TVMPANl. 

Since Sir Astley Cooper obtained a medal from the Royal Society, 
on account of the success which, in a few cases, followed the op 
tion of puncturing the membrana tympani, this operation has been 
performed frequently, and in cases of deafness arising from every 
possible cause. Though, doubtless, in certain cases it may be of 
great service, it is an operation rarely required, and one which, if 
not judiciously performed, is liable to produce the most injorious 
coneequencea. In Sir Aatley Cooper's successful cases, there 



THE E U S T A C II I 



241 



simple obstruction of the Eustuchiun tube ; and there is little doubt 
that the affection would have yielded to simple meaHures, having for 
their object the removal of the obstruction, while the cure instead 
of being temporary would have been permanent. In the great 
majority of cases where Sir Astley punctured the membraiia tym- 
pani not the slightest benefit accrued, because the deafness was de- 
pendent upon other causes than obstruction of the Eustachian tube; 
and in some cases of deafness from dchility of the auditory nerve, 
the shock of the operation greatly aggravated the symptoms. In 
what cases, then, should the operation be performed ? It will be ob- 
served that I have not recommended it in cases of obstruction of the 
faucial orifice of the Eustachian tube, because that obstruction can 
be otherwise removed ; but should the faucial orifice be permanently 
closed by adhesion of its walls (a case never met with by me}, there 
can be no question that it should be performed. It is also called for 
in cases of stricture of the osseous portions of the tube, in those of 
obstruction by fibrinous efi'usJon, and where the thickened mucous 
membrane of the tympanic orifice will not yield to other treatment. 
Great and immediate improvement frequently follows the operation ; 
hut there ia usually so much difficulty in keeping the aperture open, 
that the value of it is much diminished. The ordinary instrument 
for performing the operation is the sharp triangular end of a probe ; 
and whore only temporary efl'ect is required, this is sufficient. Fa- 
brizzi invented an instrument for drilling out a circular portion of 
the membrane ; but the extreme sensitiveness of the outer surface 
of the memhrana tympani renders it ilifficult of application. It con- 
sists of a silver tube, about four inches long, one end of which, 
about a line in diameter, ia tipped with steel and made to cut ; the 
opposite end is made to screw on the outer part of a trocar, near its 
handle ; while the trocar, consisting of a silver rod, has at its end a 
fine wire shaped like a corkscrew. When used, the trocar ia passed 
through the canula, and the spiral wire which projecta beyond it has 
its point passed through the membrana tympani, and then turned 
round so as to cause it to enter the tympanic cavity. When this 
has been effected, and a firm hold of the membrana tympani is se- 
cured, the canula is to be slightly unscrewed ; an action by which 
its cutting extremity is pressed through the substance of the mem- 
brana tympani and removes a circular portion. This instrument 
may he used, however, in cases where the sensibility of the tym- 
panic membrane has been impaired by disease. 



242 THJg DISEASES OF THE BAB. 

The usual method is, as stated, to puncture by the probe : and 
the part best adapted for this purpose is that between the handle of 
the malleus and the posterior margin. 

The plan adopted by me for keeping open an orifice in the mem- 
brana tympani, and the particulars of a case in which it was prac- 
tised, will be found below : it consists in making a triangular flap, 
by means of a very small scalpel, the blade of which is not more 
than two lines in breadth. 

Case I. Obstruction by thickened mucous membrane at the tym- 
panic orifice. — Miss K. J., aged 10, was brought to me on July 14^ 
1853. 

History, — ^Between five and six years ago, after a cold, suffered 
from an attack of earache, followed by dulness of hearing, so that 
she has been obliged to listen, in order to hear conversation. 
During attacks of cold, she has been so much worse as to require 
to be spoken to distinctly, within the distance of a yard or two. 
Is now subject to occasional attacks of earache, and has had a 
slight discharge from the right ear. On examination of the rigH 
ear, the dermoid layer of the membrana tympani was white and 
thick, and covered with a small quantity of discharge ; the mem- 
brana itself was more concave than natural ; and the Eustachian 
tube was obstructed. 

Left ear, — The surface of the meatus was covered with cerumen, 
having a natural appearance ; the membrana tympani was white 
and concave ; the Eustachian tube was obstructed ; and the mucous 
membrane of the fauces was in a natural state. 

Treatment, — Leeches were applied below each ear, twice a week, 
followed by blisters ; and the one-thirtieth of a grain of the bichlo- 
ride of mercury was given twice daily ; a course of treatment which 
was pursued for six weeks. At first, there was no improvement ; 
after three weeks, however, a slight diminution of the deafness took 
place; and on the Ist of September, the hearing was quite restored, 
and the Eustachian tubes were pervious. 

Case II. Obstruction by thickened mucous membrane at the tym- 
panic orifice^ after influenza; polypus in one ear^ a collection of 
cerumen in the other ; great improvement. — Master J. P. M., aged 
14, in good health, was brought from Lincolnshire, July 27, 1853. 

History. — Four years ago he had an attack of influenza, followed 
by so conspicuous a hardness of hearing, that he required persons 
to speak to him in a loud voice. During a cold the deafness is much 



THE EreTACniAN TUBE. 



increased ; at times, after a feeling of cracking in the ear, has heard 
much better. This crack occurred once in the right ear, after batli- 
ing, and was followed by perfect hearing for a few hours. The right 
ear has discharged blood for several months, and been affected with 
earache. Previous treatment. — Glycerine has been dropped into 
both ears without any benefit ; slight improvement followed the use 
of a blister behind each ear; tonics have been administered. 

On examination : right ear. — Hearing distance, half an inch; the 
meatus contained a discbarge, and at its inner part, concealing the 
membrana tympani, was a red, globular polypus. Eustachian tube 
obstructed. I^ft ear. — Hearing distance, half an inch : the meatua 
contained a collection of cerumen ; on removal of which, the mem- 
brana tympani was seen to be very concave and white : Eustachian 
tube obstructed. 

Treatment. — The polypus was extracted from the right ear by the 
lever-ring forceps ; Fesicatiou was kept up over the mastoid pro- 
cesses ; small doses of the iodide of potassium were administered. 
In the course of three months the hearing returned, and he remained 
well. 

CaBe Til, Obttritctlon of the tympanic orifice of the tube; polypus 
in the right ear ; cured. — Miss M., aged 14, saw me on the 14th of 
Fobrnary, 1854. He^ health was good, but she complained of head- 
ache. 

Mistory. — During the last seven years has been, at times, dull of 
hearing, and has had attacks of earache. During a cold is much 
worse. Has not had any discbarge. Occasionally, after feeling as 
if something had hurst in the right ear, had heard quite well for a 
short time. She now has to he loudly spoken to close to the right 
ear ; the left is useless. On examination, the bearing distance of 
the right ear was found to be two inches ; the membrana tympani 
was concave and white ; the Eustachian tube obstructed. With the 
left ear, the crack of the nails was heard ; the membrana tympani 
was thick ; the Eustachian tube obstructed. 

Treatment. — Brown's vesicating paper was ordered to he applied 
behind both ears every night, and three grains of hydrargyrum cum 
cretfi were to be taken every night. 

March 7th. — The same : has not been pursuing the treatment with 
regularity : to take an emetic once a week, and the one-thirtieth of 
a grain of the bichloride of mercary, twice daily ; the vesicating 
paper to be continued. 



24t 



DISEASES OF THE 



h 



April 6th. — Has heard well for a week, and hears better t 
than on March 7th. A emnll vascular polypus is seen in the TiA 
meatus near the membrana tympani. 

May 11th. — The right ear has greatly improved ; hearing distana; 
nine inches. Left oar : watch heard on pressure. 

June 14tJi. — Right ear cured: the polypus baa disappeared. 

Case IV. Ohgtrnction of tlie tympanic orifice of the tube ; temp9* 
rary reli^ by jmncturing the membrana tympani ; cured bt/ removitig 
the obgtruction. — J. R., Esq., aged 53, strong, and In good health 
was sent to me hy Mr. Cock, on May 7lh, 1853. 

History. — When a boy, was deaf, and was taken to Sir Astiey' 
Cooper, who punctured the drum of each ear ; which operation y 
followed by complete relief until eight years ago, when, after a vio. 
lent cold, deafness gradually came on in both ears; and has remained 
till now, with the exception of a day or two's improvement, at times, 
after violent sneezing. At present, he has to be loudly spoken to 
within a foot of his head, in which there is a feeling of constriction 
and of pressure on the top part. On examination of right ear, th* 
crack of the nails only is heard : the membrana tympani is very 
opaque, uneven, and concave ; Eustachinn tube obstructed. Left 
ear. — Watch heard on pressure, Membrana tympani and Eusta- 
chian tube in the same state as in the right ear. 

There was no doubt in my mind that the cause of the deafness' 
was a thickened state of the mucous membrane at the tyinpanie a 
fice of the tube; and I prescribed the application of leeches below 
the ear, to be followed by blisters, while small doses of mercury 
were to be administered. The patient, however, implored me, if 
possible, to render him some immediate relief, as he was a candi- 
date for a public appointment ; for, although my assurance that he 
would recover might favorably influence the committee, before whom 
he was to appear the following day, still he greatly feared th»t, 
should he not hear what was said, he might be rejected. I, there- 
fore, but unsuccessfully, attempted to pass air into the tympanum 
through the catheter. I then punctured each membrana tvmpani 
with an ordinary probe, which, as it passed, conveyed the feeling of 
the membrane being soft and flaccid. The result was an instanta- 
neous return of the bearing power, and the total disappearance of 
the weight in the head : to use his own words, he "felt free again." 
The hearing distance of each ear was six inches." 

May 30th. — After the operation, continued to hear well until » 



THE EUSTAOniAN TUBE. 



245 



few days ago, when the deafness slowly returned, and he is now 
nearly as deaf as on the 14th. The orifice in each memhrana tym- 
pani had closed. As he was unable to wait until the remedies for 
opening the tube could be tried, I made a triangular flap, about two 
lines long, and a line broad below, in each membrane, by means of 
a scalpel, the blade of which was about two lines in breadth: the 
apex of the flap was above, and it was turned down. The result 
was as instantaneously favorable as in the previous operation : and 
as it was considered probable that the aperture would close, active 
treatment for the purpose of opening the tube was at once carried 
out. The consequence was, that in a fortnight, although the orifice 
in each memhrana tjmpani had closed, the air passed freely through 
the Eustachian tube, and the patient heard well. 

Closure of the tympanic orifice of the Eustachian tube by the effu- 
sion of fibrinc will he spoken of when describing cases of the efi'usion 
of fibrine into the tympanic cavity. 



I 



{d.) OBSTRUCTION OF THE UIDDLE PART OF TDB EDSTACHUN TUBE; 
BY A COLLECTION OF MUCUS, BY A BTRICTUHE OP ITS CARTILA- 
GINOUS OR OSSEOUS PORTIONS, OR BY BANDS OP ADHESION CON- 
NKCTIKQ THE WALLS. 

In the tabular view giving the result of 1523 dissections, it will 
have been observed that in thirteen instances the Eustachian tube 
contained mucus. In my opinion, however, a collection of mucus 
rarely offers insuperable resistance to the action of the muscles of 
the tube, to the pressure of the air in the fauces during the act of 
deglutition, or to an attempt at a forcible respiration, with closed 
nostrils, &c. It is nevertheless possible that in some of the cases 
where the tympanic orifice of the tube is closed by thick mucous 
membrane, there may he also an accumulation of mucus : but as its 
presence would not require any alteration in the treatment, it is un- 
necessary to dilate upon the subject. 

Stricture of the osseous portion of the Eustachian tube is very 
rare. Only one case has fallen under my observation ; but as I had 
the opportunity of seeing the patient during life, and afterwards of 
making a dissection of the ear, it is of suflicient interest to be de- 
tailed at length. 

Cate I. Stricture of the osieout portion of the Eustachian iwA* ; 



246 THE DISEASES OF THE EAB. 

dissection. — G. J., aged 45, was visited by me in the month of 
November, 1849. He was dying from tubercular disease, so that I 
was precluded from making so minute an examination as would have 
been desirable. The history of the origin and progress of the deaf- 
ness, as far as could be ascertained, was as follows : — About twenty 
years ago, the patient suffered from a violent inflammation in the 
right ear, followed by a discharge from the external meatus, which 
had continued almost without intermission up to the time he was 
seen by me. For a considerable period this ear had been unable to 
distinguish sounds, and the left ear had been gradually growing less 
and less sensitive to sonorous vibrations during the preceding six or 
seven years. No pain had been felt in it, however, and there had 
been no discharge from the external meatus. 

Upon inspection by means of a speculum and lamp, the membrana 
tympani of the right ear was observed to be absent, while the mucous 
membrane lining the tympanic cavity was very thick, and covered 
by a large quantity of purulent matter. In the left ear^ the lining 
membrane of the external ear was slightly reddened, and the mem- 
brana tympani was as white as writing paper ; while the handle of 
the malleus, usually so distinctly seen, could not be distinguished 
from the surrounding membrane. Towards its centre, the surface 
of the membrana tympani had lost the natural shining appearance ; 
but a small portion of its surface, on each side of the handle of the 
malleus, although perfectly white, was so smooth as to reflect the 
light of the lamp. As the patient was in a state of great debility, 
the otoscope was not applied to either ear to test the condition of 
the Eustachian tube. The patient died a few days after the exami- 
nation. 

Post-mortem inspection. Right ear, — The mucous membrane 
lining the tympanic cavity was thick and in parts ulcerated ; while 
the bone forming the upper wall of the cavity, with which the ulcer- 
ated membrane was in contact, was carious. The Eustachian tube 
was healthy. 

Left ear, — The central portion of the membrana tympani was 
found to be white and thick ; but those parts of it which lie ante- 
riorly and posteriorly to the handle of the malleus, were soft and 
attenuated, and the white appearance was due to the presence of 
mucus in the tympanic cavity, in immediate contact with the inner 
surface of the membrana tympani. So softened was this portion of 
that membrane, that on applying the slightest pressure, the fibres 



THE EtrSTACHIAN TUBE. 



247 



composing it gave way, and three small orifices were produced. 
The cavity of the tJ^opanuln and tlie mastoid cells were filled with 
thick, white mucus, and no air was discoverable. The mucous 
membrane lining tbe cavity was also thicker than natural. 

The Emtachian tube. — The internal portion for the length of 
half an inch was healthy ; but at about that distance from the cavity 
of the tympanum, there was a sudden constriction, and for the 
length of about a line and a half the tube was so contracted, that, 
even when its superior wall was removed, it was with difficulty that 
an ordinary sized bristle could be introduced into the opening. 




This stricture resulted from the external and interna] walls of the 
tube pressing against each other ; the small space still permeable 
being at the upper part. The more remote cause of the stricture 
would appear, however, to have been an enlargement of portions of 
the bone constituting the external and internal osseous walls of the 
tube: the former being at this part twice its natural thickness, and 
somewhat rough, while the latter was forced outwards by the ddata- 
tion of the carotid canal, which, pressing thus upon the cartilaginous 
portion of the Eustachian tube with which it was in contact, pro- 
duced a flattening of the natural concavity of the internal wall. 
The mucous membrane lining the Eustachian lube was in a nataral 
state. 

Although three dissections are recorded of adhesion between the 
■walla of the tube by means of membranous bands, I have not hitherto 
met with a case during life. In such an instance the treatment 
would consist in puncturing the membrana tyrapani, and establish- 
ing an orifice in it. 




Anatomical Observations. — The tympanic cavity ia lined tbrougb- 
out by a fine membrane, wbich formtt the internal layer of the 
membrana tympani, and from which it can soinetimeB be detached 
without difficulty. Internally it covers the surface of the pro- 
montory and the membrana propria of the fenestra rotunda; it is 
reflected from the promontory at the circumference of the fenestra 
oralis upon the surface of the stapes, and it envelopes the incus 
and malleus, by means of which it is continuous with the inner 
layer of the membrana tympani ; above and below that membrane 
it covers the osseous walla of the tympanum, and is prolonged 
posteriorly into the maatoid cells, while anteriorly it is con- 
tinuous with the lining membrane of the Eustachian tube. The 
mucous membrane of the tympanic cavity, in a healthy ear, is 
BO extremely thin uh to bo quite transparent; and its presence 
upon the surface of the osseous walk and ossicles of the tympanum, 
can often only he detected by the use of a magnify in g-glasa and by 
the touch. In a natural state the nervous filaments upon the but^ 
face of the promontory are very distinctly seen, the margin of the 
fenestra rotunda is defined and regular, and the membrane which 
occupies it is thin and transparent. The crura of the stapes, as 
well as their point of connection with the base, are clearly seen, 
and a distinct fissure ia observable between the inferior surface of 
the crura and the promontory. The quantity of mucus covering 




THE CAVITY OF TB 



TYMPANUM. 



249 



this membrane in a healthy ear is bo small as to be scarcely per- 
ceptible. Tbe membrane itaelf is composed of extremely fine and 
delicate fibres, and it lias a strong analogy with the serous mem- 
branes : first, in respect to its extreme tenuity and great smoothness ; 
second, in the frequency with which membranous hands connect 
together various parts of the tympanic cavity. Over its surface 
extends a layer of very minute epithelial cells, some of which are 
ciliated. The supply of bloodvessels is abundant, though they are 
BO minute as not to be discernible, except when distended with 
blood ; this happens in disease, and then they are often very much 
dilated and surcharged. In young persona the membrane is highly 
vascular, and, when successfully injected, is found to be pervaded 
by plexiform ramifications. Beneath tbe mucous membrane lie 
the brandies of the tympanic nerve from the glosso-pharyngenl. 

The upper wall of the tympanum is formed by a layer of bone 
which separates the tympanic cavity from that of the cerebrum, 
and which deserves special attention, inasmuch as the diseases of 
tbe tympanum, which affect the brain, usually advances through 
that bone. Its form is an elongated oval, and it measures about 




three-quarters of an inch long and from a quarter to half an inch 
in breadth. Its direction is obliquely inwards and forwards, like 
that of the petrous bone. Externally it is attached to the lower 
part of the squamous, and internally to the outer part of the 
petrous, bone : anteriorly it is continuous with the roof of the 



250 



THE DIBBASE8 OF THE KAB. 



Enstachian tube, and poBteriorlj with the roof of the hoiuMital 
portion of the mastoid cells. This oBaeous Ismiaa, forming th« 
npper vail of the tympanum, varies much in thickness, being in 
some instances from half to an entire line thick, though more 
frequently it is very thin, presenting a mere shell of translnceDt 
bone. In many speciraeDS this lamina is deficient in parts, sad 
the mucous membrane of the tympanum is in contact with the dura 
mater covering the petrous bone. In some specimens in my pos- 
session, the head of the malleus projects through an orifice in this 
portion of the bone, and was directly covered by the dura mater. 
This defect in tlic upper wall of the tympanum is not usually the 
result of disease, but of the process of development. In the 
specimen, of which the following is a repr^eutation, the hoii- 




ipper Oaetoai Wall of th* T^mpsDam deraatire. 



zontal lamina alone is absent, while the vertical septa extend 
upwards, even above the surrounding surface. 

It has been thought desirable to he thus particular in the descrip- 
tion of the relations of the tympanum, because frequent reference 



THB CAVITY OF THB TYMPANUM. 251 

is made to the description in the pathological details subsequently 
entered into. 

Pathological observations. — The diseases of the tympanic cavity 
are numerous and important. Perhaps the most common affection 
to which the organ of hearing is subject, is a greater or less degree 
of thickening of the tympanic mucous membrane, with or without 
catarrh through the membrani tympani. Besides this affection, a 
simple accumulation of mucus in the tympanic cavity is of great 
frequency; and, finally, anchylosis of the stapes to the fenestra 
ovalis is a most common disease. 

The diseases of the tympanic cavity, as revealed by the dissection 
of 1013 diseased ears, are as follow : — 

CONTENTS. 

Maciu, 65 

Blood, 6 

Blood and maoas, 1 

Blood, macQs, and lymph, 1 

Serum, 10 

Sernm and mneus, 3 

Serum and lymph, 1 

Lymph, 6 

Epithelium, 2 

Epithelium and oil, . . 1 

Scrofulous matter, . . 20 

Calcareous matter, 8 

Cerumen, • . 1 

Cholesterine, , 1 

Cholesterine and mucus, 5 

Cellular tissue, 2 

Oily matter, 1 

Pus, IT 

STATE or THE MUCOUS MEMBRANE. 

More vascular than natural, 76 

Thicker than natural, . • 211 

Thick and very vascular, 16 

So thick as to conceal the stapes, 27 

So thick as to fiU the tympanic cavity, 6 

Ulcerated, 24 

Pulpy, 6 

Containing hlack pigment cells, 2 

Having serum beneath it, 1 

MEMBRANOUS BANDS BETWEEN. 

Malleus and promontory, 6 

Malleus, incus, and promontory, . . .1 



252 THE DISEASES OF THE EAR. 

Malleas and stapes, • .1 

Malleus, stapes, and promontory, .6 

Incus and promontory /.. . .5 

Incus, stapes, and promontory, .8 

Incas and malleus, .1 

Stapes and promontory, the mucous membrane being healthy, .79 

Stapes and promontory, the mucous membrane being thick, . . . .48 

Stapes and promontory, the mucous membrane being vascular, . . .6 

Stapes, promontory, and pyramid, .1 

All the ossicles, .30 

All the ossicles and the promontory, .9 

Tensor tympani muscle (the tendon) and the stapes, ... . .3 

Chorda tympani nerve, incus, stapes, and promontory, . . ... .2 

Chorda tympani nerve and upper wall of tympanum .1 

MALLEUS. 

Adherent to the promontory .1 

Absent, apparently from caries or ulceration, ..... .4 

Partly removed by caries, .1 

Malleus and incus lying in the mastoid cells, ...... .1 

Fixed by ligamentous anchylosis to the upper wall of the tympanum, . . 3 
Fixed by osseous anchylosis to the upper wall of the tympanum, ... 2 

The body anchylosed to the incus, . • .3 

The long process detached from the membrana tympani, .... 3 

The long process fractured, .1 

The long process in contact with the promontory, 3 

The long process adherent to the incus, 1 

The long process detached from the body .1 

The long process absent, .2 

The long process carious, ......... .3 

The long process exostosed, .1 

INCUS. 

Absent, .4 

Long process absent, 2 

Partly removed by caries 8 

Disconnected from stapes, 14 

Disconnected from stapes and malleus, . . * .1 

Fixed by membranous anchylosis to the orifice of the mastoid cells, . . 2 



STAPES. 

The base anchylosed by bone to the fenestra ovalis, ..... 49 

The ba^e anchylosed by bone to the fenestra ovalis, the base being expanded, 6 

The base anchylosed by membrane to the margin of the fenestra ovalis, . 36 
The base anchylosed by membrane to the margin of the fenestra ovalis, the 

base being expanded, • .... 6 

The base anchylosed by membrane to the margin of the fenestra ovalis, an 

exostosis surrounding the fenestra, ........ 2 

The base of the stapes attached to the fenestra ovalis more rigidly than natu- 
ral 66 



THE CAVITY OF THE TYMPANUM 

The hKse proJAoting into th« QKTtty of iha testibule, 

Tbe baM eipsiided and more fixed than DHtnnil 

The hue expanded and projeeting into (he veatihale, . 
Detached from inuug and attached to Itie iDEaibrB,DS tirmpani, 

Ancb^loaed to iiioii» 

Detached from the faae^tra ovnli* and the incaf, .... 

Diiconnested from the feneitra dtaUs, 

Partian;- absorbed 

Atrophied 

Abient, aiiparenl); from olcrration, 

Lex moTable than natural. 

Absent, apparenll; fram ulceTntiiin 

DisuonDocled frDin eiich other 

Carious, 

OSSEOUS VALLS. 

Thickened 

Carious, 

Upper Hall pnrttf deltcient 

Lower wall partly deflcient 

Oiseoue lamina between msitoid cella and lateral ainui ineamplete, 

Canal for portio dura nerre incomplet*, 

Carotid canal contracted 



Upon reference to Mr. Hlnton's valuable paper on the Pathology 
of the Ear, publisLed in the thirty-ninth volume of the " Medico- 
Chirurgical Tranaactions," it will be found that the results at which 
he has arrived agree with those quoted above. 

The plan I purpose to follow in investigating the subject will be 
to consider successively the affections of the mucous membranes, 
and those of the ossicles. 



{«.) COKGESTIOS OF TJIB MCt'ODS MEMBRANE OF THE TYMPANUM. 

Congestion of the tympanic mucous membrane usually follows a 
cold, or an attack of influenza. The symptoma are a feeling of dead- 
ness in the ears, sounds like the ringiiif; of bells, dulness of hearing, 
and not unfrequently slight pain. If neglected, this affection is 
liable to advance to acute inflammation. It frequently accompanies 
' congestion of the mucous membrane of the fauces and of the Eusta- 
chian tubes. On examination, the surface of the membrana tympani 
is sometimes observed to be very shining, and in other cases opaque. 



254 THE DISEASES OF THE EAB. 

The hearing power is but slightly diminished. The treatment con- 
sists in applying leeches below the ears, and using gentle coimter- 
irritation over the mastoid processes. The symptoms commonly 
yield in a few days. 

Case I. — Mrs. B., «t. 40, was sent to me by a medical man in 
1853. She enjoyed good health. 

^History, — Has not suffered from any affection of the ears until a 
fortnight since, when, subsequently to an attack of cold, a feeling 
of numbness, and a sound as of the ringing of bells, supervened in 
both ears. There was also, at times, a shooting pain in the right 
ear. On examinatioriy the mucous membrane of the fauces was ob- 
served to be red. 

Right ear, — The membrana tympani was rather more opaque than 
natural ; the hearing power natural ; the Eustachian tube pervious. 

Left ear, — Membrana tyrapani opaque ; hearing distance three 
inches; Eustachian tube pervious. 

Treatment. — Slight counter-irritation, by means of a stimulating 
liniment, was kept up over and around each ear, and in the course 
of ten days the symptoms were wholly removed. 

Ca^e II. — Mrs. P., get. 73, consulted me in July, 1853. 

History. — Six weeks previously had an attack of influenza, which 
was succeeded by considerable pain in the right ear, followed by a 
sensation of "pumping'* in the ear, which has continued to the pre- 
sent time : recently deafness of that ear has been complained of, 
and the voice appears to come out of the ear. 

On examination^ the membrana tyrapani and Eustachian tube 
appeared to be normal ; but the hearing power was so diminished 
that the watch was heard only when pressed upon the ear. 

Treatment. — A leech was applied below the ear, and the symp- 
toms abated ; counter-irritation was then resorted to, and by degrees 
all unpleasant sensations vanished. 



(6.) ACUTE INFLAMMATION OF THE MUCOUS MEMBRANE OF THE 

TYMPANUM. 

I have not hitherto been enabled to distinguish between acute in- 
flammation of the mucous membrane of the tympanum and that of 
its fibrous membrane, the periosteum, which is subjacent to it. 
When the delicacy of these membranes is taken into consideration, 



■ITT OF THE TYMPANUM. 



255 



and their intimate uDion 8o as to form one membrane of such ex- 
treme tenuity that ita presence in tlie healtliy ear can only be de- 
tected by the closest examination, it would be a source of surprise 
if acnte inflommation were to attack either of these structures with- 
out involving the other; although in many cases doubtleEs one of 
them is more specially implicated. In the description of acute in- 
flammation of the mucous membrane of the tympanum, the perios- 
teum will therefore be included by ino, especially as the syinptoma 
to be detailed appear to indicate that the view just advanced is cor- 
rect. If the mucous membrane of the tympanum be examined 
during an attack of acute inflammation, an opportunity for which is 
sometimes afforded when a patient suffering from this affection dies 
of some other disease, the bloodvessels are bo large and so nume- 
rous, that upon a cursory inspection the membrane seems as if it 
were covered by a layer of dark-colored blood. On more accurate 
inspection, however, it is observed that this blood is confined to the 
cavity of the vessels, and that the latter are completely distended 
in every part. 

The exciting cause is usually exposure to a draught of cold air, 
or sudden change of temperature. In its milder form this affection 
is met with in children, aud known as earache; for although the 
paroxysms of pain are often very severe, the symptoms are generally 
confined to the ear, and do not produce much constitutional disturb- 
ance. In children it is evident that the mucous membrane is more 
affected than the periosteum ; and porbapa one cause of the compa- 
rative mildness of the affection in the young, is, that the tympanic 
fibro-mucous membrane is laxer and more extensible than in the 
adult. 

In cliildren attacks of acute inflammation of the mucous mem- 
brane of the tympanum are apt to be greatly neglected, and conse- 
quently they frequently recur in the same child ; and even if they 
do not at the time produce a serious lesion of the membrana tym- 
pani or obstruction of the Eustachian tube, they probably lay the 
foundation of deafness in after life, by causing a permanent thicken- 
ing and rigidity of the membrane : membranous anchylosis of the 
stapes seems also to originate in this manner. When called to see 
a child suffering from inflammation of this membrane, a medical 
man will generally find that the membrana tympani is very smooth 
and shining, and more or loss red in color, according to the degree 
of distensioQ with blood of the ve&sels of the mucous membrane 



256 



THK DIBEASES OF TEE EAK, 



forming its inner layer. Sometimea this latter membrane" 
come thickened, giving a Boddcn appearance to the membraQa t; 
pani; a condition liable to occur also when the tympanic ca' 
contains an accumulation of mucus. It commonly happeos that 
children the chief pain is felt at night, when the recumbent posid 
and the heat of the pillow favor the congestion of the membrai 
Although the child may not complain of pain in the dsTtime, a 
when Been hy the surgeon may even be cheerful, still, should w 
appearance of congestion remain, or, tested by the watch, any di 
ness of hearing, it is important to apply one or two leeches belt 
the ear, and to keep up a slight discharge behind it. 

In the adult, this affection is usually of a much more formidi 
nature, and it sometimes has a rheumatic or gouty character, 
first symptom is a sense of uneasiness in the ear, which becomes 
during motion, pressure on the organ, the act of deglutition, or ttii 
use of the pocket-handkerchief. This uneasiness soon amounts 
continuous pain, which, in severe cases, rapidly increases until it b 
comes so intense as to bo scarcely endurable ; and extends over ti 
mastoid process, the whole of the affected side of the head, down tbA 
neck, and into the fauces. The power of hearing rapidly diminishes^, 
and a variety of the most horrible sounds are experienced ; soaiBr 
times described as like the hissing and puffing of a steam-engine, 
varied by .others like a series of explosions in the ear, or the ringing, 
of bells. A symptom of this affection which adds greatly to the suf- 
fering of the patient, is the impairment of the functions of the broia 
sometimes amounting only to a confusion of ideas, frequently accom- 
panied by extreme fear and depression of the nervous system, c»n»- 
ing the worst forebodings as to the result of the attack ; in other, 
cases delirium supervenes, an<l in the most formidable cases death 
takes place, from the inflammation extending to the membranes of 
the brain. Where only some of these symptoms, and those of a less 
violent character are present, the surgeon may doubt whether the 
affection is in the tympanic cavity or in the meatus. An examina- 
tion of the car with the speculum and lamp will decide the quw- 
tion ; for in the affection under consideration, there is no appear- 
ance of inflammation in the dermoid meatus or in the membrane 
tympani. The modes in which this affection terminates are the for- 
mation of lymph ; the effusion of serum into the tympanic cavity, 
which escapes through the Eustachian tube into the fauces ; or a 
copious secretion of pus or mucus, which distends the tympani 



np THE TYMPANUM. 



257 



CTLnscs ulceration and perforation of all the laminae of the mcmbrana 
tympani, and ends in abundant discharge. In some cases there is 
no indication of any secretion occurring in the tympanum, and the 
affection seema to terminate by resolution ; in others, the dermoid 
meatus pours out a sympathetic discharge without the presence of 
any orifice in the membrana tympajii. The prognosis in cases of 
this disease is favorable, and it is a great consolation to the patient 
to be aasured, amidst the very distressing symptoms from which he 
suffers, that no permanent injury need be apprehended. It would 
appear that a eingle attack of inflammation of the fibro-mucous mem- 
brane of the tympanum, however violent it may be, does not leave 
behind it that rigidity and dulnees of hearing which is a sequence of 
the attacks of a milder character occurring in children. When an 
orifice forms in the membrana tympani, it usually closes without 
difficulty ; and the power of hearing is in two or three weeks com- 
pletely restore<l. In some, but fortunately rare casea, the inflam- 
mation extends to the petrous bone, and thence to the membrane of 
the brain, causing death. It not nnfrequently happens, however, 
that the inflammation extends to the portio dura nerve in the aque- 
duct of Fallopiua, and partial or complete paralysis of that nerve is 
the result ; which is removed as soon as the inflammation has wholly 
subsided. 

The treatment of this affection consists, in the first place, of the 
local abstraction of blood by leeches or cupping ; the leeches being 
applied at the orifice or behind the ear, and the cupping practised 
directly below it. Leeches may also be applied to the nostrils. 
Vapor baths should frequently he applied to the ear, so as to allow 
the ateara to penetrate as far as the membrana tympani. The throat 
should be repeatedly gargled with hot water. The patient is to be 
kept perfectly quiet, as the least excitement or exercise is apt to 
aggravate the symptoms materially ; the room should also be dark- 
ened, and every sound excluded as much as possible. The use of 
mercury will be found very efficacious, especially when combined 
with full doses of opium or morphia. When the pain is very in- 
tense, it is desirable to keep the patient for several houra under the 
influence of opium. In the early stages of the affection tartar emetic 
proves advantageous. As soon as the discharge appears, the meatus 
should be gently syringed with a copious supply of warm water 
thrice daily. 

Id children the treatment may usually be less active ; but it is 
IT 



GABil 



^ 



important to try the application of leeches and conDter-irril 
thoroughly to subdue the infiammatioD as rapidly as possible. 

Cage I, Acute injlammalion of the jnueou» membrane of the 
panum ; perforation of the membrana tympani. — C. C, aged 
sent for me in November, 1852, on account of a severe attack 
pain in the right ear. 

History. — Two days previously ho had been exposed to a 
wind, which was followed towards night by pain in the ear. 
the night the pain became much aggravated, and seemed not 
be in the ear, but to extend over the whole of the side of the b< 
and especially over the region of the mastoid process. There 
also great constitutional disturbance, confusion in the head, and 
most extraordinary noises. " At the same moment," said the pa- 
tient, •' I seemed to be standing at the side of a stcam-eogine, snort- 
ing, puffing, and hissing, and yet hearing the sound of a church- 
tolling at a distance." 

On examining the ear, the membranous meatus was observed 
he red, the memhrana tympani dull and opaque. The patient 
very excitable ; pulse quick ; skin hot. Leeches were ordered 
be applied immediately below and at the back of the car, to be 
lowed by hot fomentations and poultices. Calomel and opium were 
administered. Under this treatment, with the addition of a blister 
to the nape of the neck, in three days the sj-mptoms gradually sub- 
sided. At the end of the third day, while the bead was on the 
pillow, a feeling us of something bursting in the ear was expe- 
rienced. This was followed by a discbarge from the ear, and a con- 
siderable additional relief to the pain. On further examination, a 
small orifice was detected in the lower part of the membrana tyin- 
pani, through which viscid mucua escaped from the tympanum. 
There was also great dulness of bearing, which was the more dis- 
tressing to the patient from hia having lost the use of the other tu 
during childhood. The perforation was regarded by me as a favor- 
able s^'mptom, being likely to prevent the formation of membranona 
bands in the tympanic cavity. The inflammation slowly Bubdded; 
the aperture in the membrana tympani closed ; and, in the courM of 
ten days, the patient heard as well as before the attack. Hia hear- 
ing has since continued good. 

In some cases of acute inflammation of the mucous membrane of 
the tympanum, the pain in the ear is not so violent as in the case 
just detailed ; but the symptoms of cerebral disturbance are mor« 



i 



THE CAVITT OF TUB TYMPANUM. 



259 



distressing and continuous. One reason for the eases of less active 
inflammation assuming the chronic form, seema to me to be, that a 
much smaller quantity of mucus being secreted, the membrana tjm- 
pani does not give way. The consequence is, the mucua collects by 
degrees in the tympanic cavity, and thus keeps up a constant, though 
slight, irritation. In these chronic cases the symptoms often dis- 
appear after a discharge from the ear ; and careful inspection shows 
that there is no perforation of the membrana tympani, and that the 
discharge does not originate from the tympanic cavity, but has its 
source in the dermoid meatus ; being the result simply of the irrita- 
tion of the tympanic mucous mcmbruie. 

The following ease will illustrate the preceding remarks. 

Caee II. Acute injlammation of the muoout membrOTie of the tym- 
panum ; frolongeA pain in the head ; discharge from the meatus ; 
relief. — M. A. K., aged 26, was admitted imder my care in St. 
Mary's Hospital on October 6th, 1854. 

History. — About a month ago she complained of pain in the face 
and soreness of the throat, together with pain in the right side of 
the head. These symptoms were followed by deafness in the right 
oar. At the time of admission she complained of pain and throb- 
bing in the right ear, extending inwards down the throat. On exa- 
mination, the tongue was found slightly furred, the pulse 84 and 
small. The surface of the meatus was red, and the vessels of the 
dermoid layer of the membrana tympani were distended. Tlie crack 
of the nail was heard when made close to the ear. Air passed into 
the tympanic cavity. 

Treatment. — Leeches were applied below the car ; and an evapo- 
rating lotion around it. 

October 12th. — Pain much the same. To repeat the leeches and 
take half a grain of the chloride of mercury, and a quarter of a 
grain of opium every night. 

October 16th. — Pain somewhat leas, but still severely felt deep in 
the ear. 

October 20th. — To repeat the leeches. 

October 24tb. — Much better ; has had an abundant di.'icharge 
from the ear, followed by immediate cessation of the pain. On in- 
spection, it was seen that the discharge had issued from the surface 
of the meatus ; and there was no perforation of the membrana 
tympani. 

Cetoher 28tb, — The pain has totally disappeared. 



260 THE niSEABES OP THE KAR. 

1. Acute injtammation affecting the portio dura nen-e. — It Uvrell 
IcnowD that the portio dura nerve passes through the aqueduct of 
Fallopius along the upper nnd posterior wall of the tympanum ; bat 




it not unfrequcnily happens that tlie inner 
is incomplete, and thus the mucous membrane 
in contact with the outer surface of the nerve, 
inflammation of the tympanic mucous merab 



wall of this canal 
the tympanum 
In cases of acute 
ne, therefore, the 



i 

anal 

m is I 



nerve often becomes afl"cctcd, cither by the prolongation of iho ia^ 
flammation from the mucous membrane directly to the nerve, <*, 
through the wall of the canal. In some of these cases tlic men- 
brana tympani ulcerates, and there is a copious discharge trom tht 
tympanic cavity; in others it remains intact. 

Case III. Acute inflammation of the mucoui mevibrane of fAc 
t^panum; ulceration of the memhrana timpani; 'paratyeia of Ott 
portio dura nerve ; cure. — E. I., aged 23, was admitted under wj 
care at the St. George's and St. James's Dispensary, on Febntltf] 
28th, 1843. 

Sittory. — lie stated that three months previously he waa suddenly 
seized with a violent attack of pain in the right car, which extondoq^ 
over the side of the head. After the pain had lasted for abod 
twenty-four hours, hu experienced a sensation of something harA 
ing in thf ear, followed by an abundant thick and offensive-smellbi 
discharge. During the attack of pain he had much giddiness, lod 
the use of the right side of tie face, and could not shut his rigk 
eye, while the mouth was drawn to the left side. On examinatittm^ 
an orifice was observed in the right memhrana tympani ; the mucoii 
membrane of the tympanum was red and thick, and poured out I 
mucous discharge, lie was ordered to apply a blister hehind tin 
ear, and became hotter, having no return of the pain till M«i 



THE CAVITY OF THE TYMPAN0M. 



261 



Ilth, when it suddenly reappeared in great violence, accoropanicd 
by 11 singing and by sensations of pumping and throbbing in the 
ear. These symptoms were much aggravated by coughing. The 
discharge was abundant, and the mucous membrane of the tym- 
panum very red. Leeches were applied below the ear, which was 
often syringed with warm water ; and after the pain was somewhat 
subdued, a blister was applied behind the ear. Calomel and opium 
were administered until the gums were rendered tender. The symp- 
toms gradually subsided. 

April 11th. — Improved, and complains of but little pain. 

April 16th, — The discharge is much diminiBhed ; the orifice in the 
membrana tympani is smaller ; and the singing noise not so loud. He 
cannot yet close the right eye or use the mouth freely, but the power 
over the muscles of the face is certainly greater. Ordered to rub the 
ointment of tartarized antimony behind the ear. From this time the 
patient gradually improved, and on the 3d of July the portio dura 
nerre had regained its power, and the quantity of discharge had 
much diminished. 

The following case of the same kind occurred in a younger per- 
son : — 

Case rV. Acute inflammation of the mucous membrane of the right 
tympanum ; great pain in the head ; temporary paralysis of the right 
portio dura nerve. — Master S., aged 5, pale and weakly, was brought 
to me on the 10th of February, 1850. 

History, — Three months previously, the right ear had been pulled 
rather violently. Fourteen days ago, he complained of pain deep 
in the right ear, which in two days was followed by discharge and 
relief. Lately he has so suffered from pain on the right side of the 
head, that he constantly presses it with his hand ; and for a week 
he had paralysis of the right side of th-* face ; but perfectly re- 
covered. To-day he again complains of pain in the car. On exa- 
mination of the right ear, the surface of the meatus was observed to 
be red and swollen, denuded of epidermis, and covered ||}y a thick 
white discharge ; the membrana tympani, which was in the same 
state, bulged outwards. Leeches below the ear, the use of warm 
fomentations, and the administration of tonic medicines, speedily 
reduced the pain in the ear aud head, and he was sent to the sea- 
side. On March 7th, about a month after I had first seen him, I 
found that the matter had made its way through a small orifice in 
the lower part of the membrana tympani. 



262 



8EASES OF THE EAR. 



In some cases, the portio dura nerve becomes afiect^d while thl 
patient is under treatment for secondary sypLills. Two iostimceB' 
of this kind have occurred to me. In one, the patient was a man of 
twenty-three, who stated, that six montha previous to his consulting 
me, he had complained of pain in his left ear for two or three day^ 
when he suddenly lost the use of the left side of the face, aod found 
that he could not close the left eye. On examination, the left i 
brana tympani was rather opaque, although its surface was smooth. 
On swallowing with closed nostrils, and in forcing the air, it passed 
freely into the right tympanic cavity, but not so freely into the left 
The patient was treated with small doses of iodide of potassium, and 
by the application of ointment of tartarizoil antimony behind th« 
ear. After six weeks of this treatment, there was scarcely any trace 
of the paralysis of the muscles of the face, and the hissing sound had 
greatly diminished ; hut the deafness remained as before. 

2. Acute infiamviation extending to the brain. — In some cases, 
the inflammation advances from the tympanic cavity to the brain, 
and death is the consequence. The following illustrative case ii 
taken, in an abridged form, from Itard.' 

Case V. Acute inflammation of the mucous membrane of the tympa- 
num ; inflamjnation of dura mater ; death. — J. B., aged 26, of a san- 
guine temperament and robust constitution, was received into the 
military hospital of Val de Grace, on account of an inflammation of 
the pleura. On the 6fth day of the attack, he was seized with vio- 
lent pain in both ears, but especially in the loft, and the pain 
accompanied by a rushing noise like that of a torrent. On the sixth 
day the pain increased so as to beoome intolerable, wilh throbbing 
in the ears ; pain in the head violent, pulse hard and full. The«e 
symptoms increased, with greut excitement, delirium, and stupor, 
and the patient died on the seventh day. 

On dissection of the right ear, the mucous membrane of the tym- 
panum was red, swollen, velvety, and covered by puriform mucus, of 
which thoicavity was full. The membrana tympani was entire, but 
its inner layer very thick and red. The mastoid cells were full of 
mucus. In the left car, where the pain had been the most acute, the 
mucous membrane of the tympanum and mastoid cells was of a deep 
red color, but there was no secretion of mucus. The dura mater 
covering the anterior and posterior surfaces of the petrous bone 






■ Tr4it« dM MiUdiu d« I'Onilla. Tol. !, p. IM, M tj. 



THE CAVITY OF THE TYMPANUM. 



adherent to the adjacent cerebral substance; it was red and thick, 
and separated from the bone. Between the bone and the dura 
mater, there was nearly half an ounce of a transparent gelatinous 
fluid. 

A case somewbat similar to the foregoing, I liad an opportunity 
of inspecting, after death, with Dr. Blakely Brown. 

Ca»e VI. Acute infiammation of the tympanic mucrma membrane 
after whooping-cough ; dura mater infiamed: effusion of serum he- 
tureen it and the petrous bone, and in the lateral ventricles. — The 
child was three years old, and shortly before the fatal seizure had 
gone through an attack of whooping-cough. A year and a half pre- 
vious to her death, she hail a discharge from the left ear, at first un- 
accompanied with pain, but subeeqneDtly, at times, she suffered from 
acute attacks of pain in the ear and side of the head, previous to, and 
during which, the discharge subsided. A few days before her deitth, 
one of these attacks of intense pain in the ear and head came on, and 
resisted every remedial measure prescribed, until the child died in 
the greatest suffering. 

On inspection, it was found that the whole of the membrana tym- 
pani had been destroyed, with the exception of a small semilunar 
margin at the upper and posterior part. The mucous membrane 
lining the tympanic cavity was of a deep red color, from its blood- 
vessels being enlarged and distended with blood. The dura mater 
was much congested ; serum was effused between it and the petrous 
bone, and its inner surface was adherent to the arachnoid. Serum 
was also effused beneath the arachnoid, and in the lateral ventricles. 

In cases of typhus fever, I hare found the dura mater partaking 
of the inflammation of the tympanic mucous membrane. One case 
of this kind was that of a girl, aged 16, who died of typhus fever, 
after seven weeks' illness. She was, to a certain degree, dull of 
hearing from the commencement of the attack, but not previously. 

Dissection, Right ear. — The meatus externus contained a large 
quantity of thick matter, and the dermis and periosteum were so 
soft as to be easily detached from the bone. The membrana tym- 
pani had been removed by ulceration. The tympanic mucous mem- 
brane was thick and soft, and, although the ossicles were in their 
natural position, the long process of the malleus ha<l been absorbed. 
The cavity contained thick mucus ; and the dura mater was detached 
from the upper part of the tympanum. 

L^ ear, — The meatus was full of pus ; ite lining membrane was 



2G4 



soft, and a small strip only of tlio mrmbraiia tympani remiinsd. 
The tj-mpanum and mastoid cells were full of thick muco-puraleiit 
matter; the lining membrane being tbick, soft, and discoDnected 
from the bone. The dura mater adhered so slightly to th(* upper 
wall of the tympanum, that it vras disengaged by the gentlest trac- 
tion. 

In other cases of death from typhus fever, I found the dura mater 
infiamed, and separated from tho upper surface of the petrous bone 
by scrum. In one case, that of a patient aged 17, during the attack 
of fever, but not previous to it, there was great dulnces of hearing 
for nine days, and discharge from the left ear four or five days prior 
to death. On diasection, the dura mater was found to partake of 
the inflammation of the mucous membrane ; the bone was also very 
vascular, and it was separated from tho dura water by a small quan- 
tity of serum. 

The presence of scrofulous matter in the tympanic cavity eome- 
times gives origin to the most formidable cerebral symptoms, and, 
in some cases, without leaving any traces of inflammation of the 
brain after death. In the following case, which occurred Under the 
care of Dr. Chambers, in St. Mary's Hospital, and which I had the 
opportunity of seeing during life, I think there is no doubt but that 
the cerebral symptoms arose from the affection of the ear. 

Case VII. Aecumulation of ecrofulous matter in the tympanum; 
acute inflammation of the mucous membrane ; severe cerebral symp' 
toms; death. — S. B., aged 10, was admitted into St. Mary's Hos- 
pital on the 21st April, 1854, with the following history: — Vomit- 
ing, iicat of skin, beadach*;; oceasional shrill screaming had com- 
menced on the 18th, and continued to the time of admission. The 
bowels had not acted since the liHh. She had formerly a discharge 
from the right ear ; but that Lad latterly ceased, though dea&eat 
remained. 

On examination, the pulse was rapid and regular ; the skin hot 
and dry ; the face flushed ; the eyes heavy bat shiny ;• the pupils 
naturally affected by light. There was a tendency to a sort of coma- 
tose sleep, but she was easily roused by speaking to her. 

April 21st. — Ten leeches to be applied to the head ; also ice j 
one and a half grain of calomel every hour, and a purgative in the 
morning. 

22d. — Urine albuminous, probably from the calomel. No more 
Tomiting. Bowels opened several times. Complains of pain in tbe 





TOE CAVITY OF THE TYMPANUM. 



265 



cardiac region. Kecpa boriug her head into the pillow, and occa- 
sionally screaming. No pain in the Iieiid, Tongue white and furred ; 
pulse 108, regular ; one of the evacuations was mucous and bloody, 
the rest dark. Ordered the calomel every three hours, and a blister 
to the nape of the neck. 

23d. — The aame symptoms exaggerated, with violent delirium 
occasionally and screaming, alternating with a half-comatose state. 
This continued till her death, at two in tlie morning of the 25th, 
the face and lips remaining flushed till the time of decease, 

Post-mortem Ingpeetion. — The tympanic cavity contained scrofu- 
lous matter. The mucous membrane lining the tympanic cavity 
was very red, and its hloodvesscls very distended. The whole of 
the petrous bone and the dura mater covering it, was also of a deep 
red color from the distention of the vessels, 



{(?.) CnROSro INFLAMMATION AND nTPEItTBOPHY OF THB TYMPANIC 
MUCOUS MEMBRANE. 



I am not sure that the above designation is perfectly correct, 
because it appears probable that hypertrophy of the mucous mem- 
brane sometimes takes place without the occurrence of any appre- 
ciable inflammatory symptoms ; indeed, in children having a ten- 
dency to glandular enlargements, the mucous membrane appears to 
become thickened without the slightest sign of inflammation. In 
some cases, however, chronic inflammation undoubtedly precedes 
the hypertrophy. 

Pathological Ohaervatiotit. — The mucous membrane lining the 
tympanic cavity frequently undergoes the process of hypertrophy. 
This delicately thin mucous membrane, so fine in its natural state 
as often to require the aid of touch as well as sight to determine its 
presence, may nevertheless become so thickened as to fill the whole, 
or nearly the whole of the tympanic cavity. From being like a 
piece of the finest silver paper, it becomes more like velvet. Instead 
of throwing out just so much mucus as suffices to lubricate the sur- 
face of the membrane, it pours forth a thick and viscid secretion 
which often fills up the entire cavity unoccupied by the hypertro- 
phied lining. In some cases where the Eustachian tube is partially 
or wholly closed by the hypertrophied membrane, the mucus presses 
upon the inner surface of the membraaa tympani ; gradually by its 



266 



EASES OF TUE EAR. 



pressure causing absorption, and ultimately produces an oi 
through wliich the mucus escapes into the meatiiB, giving rise to 
what was formerly called a caae of otorrhoea. This discharge 
through an orifice in the membrana tympani, in the way jnst de- 
scribed, is one of the common results of scarlet fever ; and thongh 
it does not appear probable that the mucous membrane should 
become bypertrophied in so short a space of time as that in which a 
case of scarlet fever ia developed, yet it is still possible that it may 
be 80. My belief, however, is, that in these cases of catarrh of the 
mucous membrane, hypertrophy has usually preceded the attack of 
fever; and that this condition of the tympanum and other organs 
are evidence of a weakened state of the system. Sometimes this 
condition of chronic inflammation of the mucous membrane extends 
upwards through the osseous wall, and affects the dura mater. The 
constant attacks of earache in some children are due to tins affec- 
tion. 

The predwposing ca\i«f is the most essential point to oscertun in 
respect to this affection, since it almost invariably occurs in those 
whose vital power has been lowered by disease, or some other debili- 
tating influence. Improper food or clothing, insufficient ventilation 
or exercise, or some analogous cause, may almost always be detected; 
and when detected, should be at once removed, if possible, or at least 
diminished by the skill of the surgeon ; after which, the nest step is 
to assist in remedying the effects. It will usually be observed, on 
general examination, that the cliild is pale, flabby, deficient in bodily 
strength and spirit, with the submaxillary, or ccr\'ical glands, often 
bypertrophied, and the heart weak. On inspecting the ear, the 
dermis of the meatus is commonly thicker than natural, so that the 
calibre of the meatus is diminished, and there is some difficulty in 
obtaining a distinct view of the membrana tympani ; but when the 
latter organ, or a portion of it, is seen, its surface is found to be 
less shiny than natural, and not unfrequently of a whitish color, 
resembling the appearance of parchment more or less sodden. 
Sometimes, while the long process of the malleus is unseen, the 
procesgiig brevix stands out prominently. When the Eustac&ian 
tube is also obstructed, the membrana tympani is externally much 
more concave than natural. On exploring the tympanic cavity by the 
otoscope, air is not unfrequently heard most distinctly to enter the 
cavity, although the sounds developed by its entrance are abnormal. 
Instead of the normal crackling, & flap, as of air suddenly blown 



THE CAVITY < 



267 



into a wet bladder, is heard. At times, during the act of swallow- 
ing with closed noBtnla, the air does not enter the tympanum, aiid 
a forcible expiration with closed nostrils is requisite to insure its 
ftdmiesion; but when the air is forced in, a sound similar to the last 
described is produced, but of a louder and more defined character. 
Id certain cases there is an accumulation of mucus in the tympanic 
cavity, so that vrhen air is forcibly injected a gurgling or bubbling 
sound is heard. 

Treatment. — As before stated, the first step is to discover what has 
been done or is doing in violation of nature's laws, and to insist, as far 
as possible, on a proper mode of liring. This having been attended 
to, remedial medical measures may be hopefully applied. These are, 
gentle counter-irritation over the mastoid processes by means of vesi-, 
eating plaster or solution ; and, where there is much congestion, with 
frequent attacks of pain, a leech or two may be applied beneath each 
ear ; a stimulating gargle may be prescribed, and cold water freely 
used outside the throat. The tonsils, often much enlarged, may 
be washed with a solution of nitrate of silver {twenty grains to an 
ounce), and tonics administered. In very advanced cases, where 
the health is much deranged, the child antemic, and its physical 
powers greatly depressed, it may be requisite at once to insist upon 
sea air, or at least change of air. The prognosis in these cases ia 
usually favorable ; by careful management, the mucous membrane is 
gradually restored to a more natural state ; the mucus disappears 
from the tympanic cavity, and the patient regains bis hearing in a 
month or two. Cases of a less favorable character occasionally 
occur, where the earache has been violent, the infiammation acute, 
and rigid bands of adhesion have formed in the tympanic cnvity, or 
the membranes of the articulations of the ossicles have become rigid : 
these, of course, demand longer perseverance and greater attention, 
but are usually eventually cured. 



i.) CHRONIC CATARRHAL INFLAMMATION OF THE MUCOUS MBM- 
BRANB LINIKO THE TYMPANIO CAVITY. 



This affection differs from the last in the circumstance that mucus 
has collected in bo large a quantity as to distend the tympanic 
cavity, and press upon the inner surface of the membrana tympani, 
80 that this structure, becoming gradually atrophied and yielding to 



268 THE DI8EASB8 OF THE EAB. 

the pressure of the mucus within, has given way, and the discharge 
issues through the orifice thus made. 

The treatment of this class of cases differs from that of the pre- 
ceding in the use of the syringe and warm water twice, or oftener, 
daily, to effect a complete removal of the secretion. The great 
desire of the friends to stop the discharge must be earnestly con- 
tended against, since that discharge is simply an effect and not a 
cause ; and it is the latter which requires to be removed. Among 
the causes to which attention is frequently called, is the admission of 
cold air to the delicate mucous membrane of the tympanum through 
the external meatus. In these cases, the artificial membrana tym- 
pani is to be used where the age of the child will permit it, and re- 
ference must be made to the chapter where it is described, together 
with its mode of application. 



{e.) CHRONIC CATARRHAL INFLAMMATION OF THE TYMPANIC MU00U8 
MEMBRANE AFFECTINO THE BONE, DURA MATER, OR BRAIN. 

The first effect upon the tympanic mucous membrane produced by 
scarlet fever and other predisposing diseases, is usually a simple ca- 
tarrhal inflammation, i, e.j the ciliated mucous membrane, which is 
naturally extremely thin, and pours out a very small quantity of 
thin mucus, becomes hypertropliied, and secretes copiously a viscid 
matter, which, being too abundant and thick to escape through the 
natural excretory passage, — the Eustachian tube, — gradually fills the 
tympanic cavity, and presses against the inner surface of the mem- 
brana tympani, causing the partial or entire destruction of that 
organ ; the mucus then freely escapes into the meatus, and forms 
one of the class of cases usually comprised under the term otorrhcea^ 
it being in reality a case of simple catarrh of the mucous membrane 
of the tympanum. So long as there is a free exit for the discharge, 
I believe that the disease rarely extends to the cerebrum ; and for- 
tunately, in a large proportion of cases where the ear is injured by 
scarlet fever or other diseases, so large a section of the membrana 
tympani is removed, that the viscid mucus secreted has free egress 
from the tympanum. But, as stated, the membrana tympani some- 
times remains entire, or has only a small aperture, or a part falls in- 
wards and becomes attached to the promontory, thus making a sep- 
tum, shutting off the tympanic cavity from the meatus. Sometimes 



THE CAVITY OF THE TYMPANUM. 



membranous bands stretch across the tympanum, or scrofulous de- 
posits accumulate. By ona or other of the above circumBtances, the 
secretion of the tympanic mucous membrane is prevented passing out- 
wards; and it gradually di-stenda the tympanic cavity till it aSecta 
the osseous walls ; and thus disease of the membranes of the brain, 
or of the brain itaelf, is originated. 

Although, as just stated, simple chronic catarrh of the tympanic 
mucous membrane, when there is free egress for the discharge, rarely 
extends to the brain, the dura mater may, nevertheless, become 
diseased. In chronic catarrhal inflammation the tympanic mucous 
membrane becomes much hypertrophied and its vessels enlarged; 
and as these vessels are, through the medium of the bone, directly 
continuous with those of the dura mater, it is not surprising that the 
latter membrane should be affected, and we find it accordingly un- 
dergoing slight changes. One of these is hypertrophy; another is 
detachment from the petrous hone; and the third is atrophy and 
extremely firm adhesion to the bone. The bone is also liable to be 
slightly affected. 

The following case illustrates the effects of simple catarrh of the 
tympanic mucous membrane, with free egress for the secretion. 

Gcue I. Catarrh of the tympama inucous membrane; bone soft. — 
A woman who had been deaf in both ears during many years, died 
of apoplexy, at tlie age of 64. On dissection of the right ear, nearly 
the whole of the mcmbrana tympaiii was found to have been de- 
stroyed ; the small portion which remains ia thick and soft, and is 
in contact with the promontory. The malleus has disappeared, but 
the incus remains, and is attached to the stapes; the latter bone 
being wholly concealed by the thick mucous membrane. The upper 
osseous wall is soft. 

Chronic catarrhal inflammation of the mucous membrane of the 
tympanum, where the mcmbrana tympani is entire, and where there 
has been hut slight catarrh from the mucous membrane, may also 
produce disease in the dura mater; hut so far as my experience 
extends, no cases have occurred in which the disease has advanced 
to the injury of the brain, so long as there is not more discharge 
than can pass away through the Eustachian tube. Cases of this class 
have come before me when making dissections of the ears of patients 
who have died of other diseases ; and the following brief notices 
indicate the state of incipient disease that maybe present; and 
further consideration will show that it ia likely to assume a very 



270 THE DISBASea OF THS EAR. 

serious cdnracter, wlien, under the influcDce of exciting causes, the 
quantity of the secretion is much increased, 

Diggeetion. Mucous membrane of the tympanum thick; membrana 
tympani entire ; bone carious ; dura viater ulcerated ; the arachnoid 
in contact with the tympanic mucous membrane. — A man wlio had 
been many years deaf, died of consumption at the age of 50, 
Right Sar- — The memhrana tympani is white, concave, and very 
thick, and the whole of its inner surface adheres to the inner wall of 
the tympanum, while the ossicula are firmly bound together by bands. 
The membrane lining the mastoid cells is thick, and the cells contaia 
a viscid fluid. Left. ear. — In much the same state as the right, but 
there was a carious orifice in the upper wall of the tympannm. The 
dura mater was thin in eome parts, and ulcerated in others, so that 
the outer surface of the viscera! arachnoid was in contact with the 
mucous membrane of the tympanum, 

Ditscction. Mucous membrane of the tympanum thick ; membrana 
tympani entire; bone carious; dura mater atrophied, ulcerated. — 
A woman, aged 65, died of paralysis. Many years previous to her 
death, deafness slowly came on in the right ear, after repeated at- 
tacks of earache. Dissection of right car. — Membrana tympsni 
white and thick, and a large membranous band connects the incus 
with the inner wall of the tympanum, so as nearly to conceal tha 
stapes. The tympanic mucous toembrano is four or five times itB 
natural thickness, and adheres firmly to the hone. The upper o»- 
seous wall of the tympanum is cribriform, so that at various points 
the thickened mucous membrane is in contact with the outer surface 
of the dura mater. The dura mater is very thin, and presents two 
or three small orifices. 

In another woman, aged 70, who died of apoplexy, and who had 
been many years deaf, the following was the condition of tlie left 
ear. The membrana tympani was thick and opaque, more especially 
at its posterior part ; and its inner surface firmly adhered to the 
inner wall of the tympanum and to the stapes, which bone is con- 
cealed by hands of adhesion, The upper osseous wall of the tympa- 
num is carious, and presents several large orifices, which allow the 
dura mater to be in contact with the thickened mucous membrane. 

Treatment. — Chronic catarrhal inflammation of the mucous mem- 
brane lining the tympanum is iisually attended by so extensive a 
destruction of the membrana tympani, that fortunately the discbarge 
finds a free outlet, however viscid it may be. The effects, therefore, 






THE CAVITY OF THE TYMPANUM. 271 

are confined to a. certain amount of congestion of the dura mater 
covering the petrous bone. In cases of this simple kind, it is there- 
fore not uncommon to meet with symptoina of slight cerebral irrita- 
tion, wliich graduallj yield to treatment by local depletion and 
gentle counter-irritation. The majority of these casea result from 
an attack of scarlet fever. The following is an instance : — 

Gage II. Catarrh from the tgmpanic viucout membrane after 
scarlet fever; dratruetion of each membrana tympani; attack* of 
ffiddinemi. — Miss A. H., aged 15, consulted me in November, 1845, 
on account of a discharge from each ear, accompanied by dulneea of 
hearing and frequent giddiness. She stated that seven years pre- 
viously she had an attack of scarlet fever, for which she was con- 
fined to her bed. During the fever a copious discharge ii<^ued from 
each ear, and the hearing was greatly diminishetl. For the last 
three years there has been so much less discharge, that it baa not 
reached the orifice of the ear for two or three weeks at a time ; but 
with this diminution of the discharge the deafness baa been aggra- 
vated. She now complains of frequent attacks of giddiness. 

Upon exaviination, each membrana tympani was discovered to be 
entirely absent, and the mucous membrane, which was thick and 
red, was the source of the secretion. Watch heard at one inch from 
the right ear, and at two inches from the left. The treatment con- 
sisted in the application of leeches helow the ears; the use of a 
very weak solution of the diacctute of lead as an injection after 
tepid water ; and the administration of the twentieth of a grain of 
the bichloride of mercury twice daily. Under this treatment the 
congestion of the mucous membrane of the tympanum greatly 
diminished, the discharge gradually decreased in quantity, and the 
giddiness disappeared. 

Other cases might he cited in which catarrhal inflammation of 
the tympanic mucous membrane had been accompanied by symptoms 
of giddiness ; some resulted, as in the last case, from scarlet fever ; 
others from measles. The treatment in each case was very similar; 
and although in some instances the pain extended over a great part 
of the head, and was even accompanied at times by vomiting, all 
ultimately recovered. 

In the case above cited the entire membrana tympani was absent, 
80 that the whole of the discharge could be removed by syringing. 
In those which follow, part only of the membrana tympani was 
destroyed, and the remainder prevented the egress of the matter ; 



272 THE DISEASES OF THE EAR. 

additional care had therefore to be exercised to insure the complete 
removal of the discharge. 

Case III. Catarrh from the mucous membrane of the left tym- 
panum ; perforation of the membrana tympani ; pain in the left side 
of the head. — F. H., an architect, aged 44, consulted me in 1852, 
respecting a discharge from the left ear, accompanied by pain and 
tenderness over the left side of the head. He stated that since 
childhood he had been subject to a discharge from the left ear, 
which had never ceased for more than a few days. During the last 
five or six years ho has also complained of pain in the left side of 
the head, extending in front as far as the temple, and behind over 
the region of the mastoid process. Slight excitement or fatigue 
produces considerable aggravation of the symptoms. At times, 
the pain in the ear comes on suddenly, and is followed by very 
abundant secretion. About a month ago, during a cold, he had an 
attack of pain in the ear, attended by a loud whizzing sound and 
great additional tenderness over the left side of the head. On 
examination^ an ulcerated orifice, about two lines in diameter, was 
observed in the posterior part of the left membrana tympani, 
through which oozed a large quantity of thick tenacious discharge, 
having an ofiensive odor. On removing this, the mucous membrane 
of the tympanum was seen to be red and much thicker than natural, 
so as to project towards the orifice in the membrana tympani, and 
in some degree prevent the free passage of the secretion through 
the orifice. The treatment in this case consisted in keeping up a 
discharge from the mastoid process, and in administering small 
doses of the bichloride of mercury in conjunction with sarsaparilla. 
The ear was also syringed twice daily with warm water, care being 
taken that the stream was directed to the orifice in the membrana 
tympani, so that the water might be made to enter the tympanic 
cavity, and, by mixing with the mucous secretion, so soften it as to 
facilitate its discharge through the orifice of the membrane- This 
treatment was very successful, for the pain around the ear dimin- 
ished greatly by degrees, and the attacks of pain within the ear 
became less frequent. The quantity of the discharge, however, 
remained much the same until a weak solution of the diacetate of 
lead was injected. This treatment was pursued for four months, 
at the end of which time the patient no longer complained of any 
pain in the ear or head, and the quantity of discharge had greatly 
decreased. 



TBE CAVITY OF THE TYMPANUM. 



273 



Cases similar to the above being frequently met with in practice, 
the following brief particulars of a very similar instance are sub- 
joined. 

Gate IV, Catarrhal inflammation of the tympanic mucoua inem- 
brane ; perforation of the memhrana tympani ; pain in the head, and 
giddiness; irritation of the portio dura nerve. — Miss M. S,, aged 
30, says, that since childhood, with exception of an interval of two 
years" duration, she has had a discharge from the right ear, follow- 
ing an eruption on the head. For eight or nine years has com- 
plained of pain at the top of the head, with heat and a sense of 
weight. This pain sometimes siiddenly shoots across the head from 
the right ear. She suffers at times from giddiness, and for the last 
few months has had a feeling of confusion in the head ; six months 
ago had twitchings of the muscles on the right side of the face. On 
examination, the niembrana tympani of the right ear was seen to be 
perforated at its upper and anterior part, the aperture measuring 
about a line and a half in diameter. Mucus oozed through the 
aperture, and having been removed, the mucous membrane of the 
tympanum was observed to be^ thick and red. The treatment was 
the same as in the last case, except that leeches were applied below 
the cars once a week. After three mouths all the symptoms were 
much diminished, and the patient was ordered to continue the counter- 
irritation and the injection with warm water. 

From the situation of the orifice in the memhrana tympani in the 
above case, it will be observed that in the usual position of the head 
during the day, a portion of the mucus must have been confined to 
that part of the tympanic cavity which was beneath the orifice; 
there was, however, a free escape of the mucus during the recum- 
bent position, as there was then an opportunity for the complete 
evacuation of the contents of the tympanic cavity ; and as the symp- 
toms were not very urgent, it appeared advisable to try the effect of 
counter-irritation, instead of enlarging the orifice in the memhrana. 
tympani. 

In treating the class of casea now under consideration, it is of 
great importance to be able to decide when the memhrana tympani 
should be perforated by artificial means, or when an orifice in it 
should be enlarged. To the perforation of the memhrana tympani, 
much objection exists on account of the difficulty of keeping the 
aperture open. It is seldom that a punctured aperture, even of 
large size, does not close in the course of two or three days. I have 
]8 



274 THE DISEASES OF THE EAB. 

found, even after making a triangular flap and turning it down, that 
the orifice thus produced sometimes closed in a few days by the 
efi'usion of fibrine. It is, however, not always possible to make a 
triangular aperture of this kind, either on account of the small 
calibre of the meatus, or the extreme sensibility of the surface of 
the membrana tympani. The only sure way of keeping open an 
aperture in this membrana with which I am acquainted, consists in 
applying to it the point of a fine stick of potassa cum calce. Such 
a proceeding appears, at first sight, to be attended with danger to 
the adjacent parts ; but, in reality, the action of this substance is 
wholly under control ; for the injection of warm water at once 
entirely stops its escharotic properties. During and after the appli- 
cation of this remedy, to which I have resorted in the destruction 
of polypoid growths, I have never known any inflammation to arise. 
At the same time there is no doubt, that in cases such as we are 
now considering, when there are symptoms of cerebral irritation, 
extreme caution should be used, and every other possible measure 
adopted before having recourse to this, or indeed any other operar 
tive proceeding ; and as remedial measures of a different kind are 
generally sufficient to alleviate or cure the disease, the operation of 
perforating the membrane is rarely required. The potassa cum 
calce has been used by me in only one case. 

In those cases of catarrhal inflammation where the quantity of 
discharge from the tympanic mucous membrane has not been suffi- 
cient to cause ulceration of the membrana tympani, but where the 
superabundant quantity has passed away through the Eustachian 
tube, it seems to me that, as a general rule, unless the disease has 
made great progress and threatens the life of the patient, the ordi- 
nary remedial measures already adverted to will be found sufficient 
to arrest its progress and produce considerable improvement.* The 
following cases will illustrate this branch of the subject, and it will 
be seen that they differ from those last quoted in the circumstance 
of the membrana tympani being still entire. 

Cane V. Chronic inflammation of the 7mccous membrane of the 
tympanum^ without perforation of the membrana tympani ; giddir 
nc88y ^c. — M. C, aged 27, consulted me on the 15th of February, 
1857. She said that for four months she has had at times a sensa- 
tion of pricking in the right ear, accompanied by a humming noise, 
deafness, giddiness, a sensation of swimming in the head, and pain 
over the right side. During the last few days has complained of a 



AVITY OF THE TYMPANUM. 



275 



throbbing in the ear, attended with great pain, and foUomed by dis- 
charge: has also been "light-headed"' at night. Every time she 
draws in breath through the nose, she etatea there is a rattling sound 
in the ear, and for a minute or two she hears better. The hearing 
is also better after a copious diacharge. On inspection, the surface 
of the meatus was found to be red, denuded of epidermis, and secret- 
ing a mueo-purulent fluid. The membrana tyrapani was opaque, es- 
pecially at its lower part ; the Eustachian tube pervious, and the 
power of hearing much diminished. Considering the case to be one 
of chronic inflammation of the mucous membrane of the tympanum, 
with a collection of mucus in the lower part of the tympanic cavity, 
and that the irritation of the meatus was only a symptom of this in- 
flammation, the treatment adopted consisted in the application of 
leeches below the ear, and of blisters behind it; under this treat- 
ment the head-symptoms greatly diminished, while the hearing was 
much improved. On the 12th of May, the patient was again seized 
with violent pain in the right ear, extending across the head and 
towards the forehead. On the 17th she became much worse, and 
was insensible for some hours. Blisters were applied to the nape of 
the neck, and a constant discharge was kept up through them for 
some weeks; small doses of calomel were also administered until the 
gums became tender. The acute symptoms were soon abated, but 
counter-irritation was kept up for a long period, and iodide of potas- 
eium and sarsaparilla were afterwards administered. Treated in 
this way the symptoms of cerebral irritation wholly subsided, and 
the power of hearing greatly improved. 

Although it is difficult to determine positively whether there is a 
collection of mucus in the tympanic cavity, the history and symp- 
toms of the case, and the peculiar sodden condition of the mem- 
brana tympani, such as was presented in this case, especially at the 
lower part, left little doubt in my mind that mucus had collected ; 
and the second attack was probably the result of a collection of this 
fluid, causing irritation and pressure on the labyrinth. It is pos- 
sible that more speedy relief might have been effected, by allowing 
an escape of the mucus tlirough an orifice in the membrana tyra- 
pani ; but I was quite aware, from previous operations, of the great 
difficulty of keeping open the aperture, even if the means employed 
did not cause a serious increase of the inflammation. The impor- 
tant rule to bear in mind, ia to keep up counter-irritation long 



27& 



THE DISEASES OF THE EAR. 



enough to cause absorption of the fluid, and the arrest of the inflaia 
matory action which produces the secretion. 

As stated, there is some difficulty in ascertaining positively vbo- 
ther there is a collection of mucus in the tympanic cavity. Som 
times the opacity and sodden appearance of the membrana tympsni 
IB the chief indication ; but often the gurgling sound, produced by 
the entrance of air into the tympanum, or the peculiar flap, remit' 
ing from the air striking against a soft flaccid membrane, shows, ■ 
least, that there is a considerable quantity of mucus in the cavigi^ 
The following case will further elucidate the subject : — 

Case VI. Chronic eatarrh of the mucous membrane of the i 
panum ; giddinesg, and »t/mptom» of cerebral irritatioji. — ^E. Mid- 
dleton, aged 14, was admitted under my care, at the St. George'if 
and St. James's Dispensary, in December, 1849. She had an tt^ 
tack of measles at four years of age ; since which she has coi 
plained of mucli pain in both ears and in the front of the head, a 
tended by throbbing and frequent attacks of giddiness, espocisU|^ 
when walking quickly. At times, also, she has been delirious and verj 
violent. The hcad-symptoma have much increased in severity stDOC 
the cessation of the discharge, which took place nine months pre* 
vious to her consulting me. 

On examination, the niembrana tympani of the right ear waa s 
to he very white, and parts of it had fallen in. Hearing distance, 
with watch, half an inch. Left ear. — The mombrana tympani !& 
milky white : hearing distance same as right ear. Air passes inM 
each tympanum during an expiration with cloaed nostrils, producing 
a gurgUng sound. The treatment consisted in the use of a blister* 
ing ointment to the nape of the neck, by which a constant discliargt 
was kept up for more than a month, and in giving tonic mcdicinesi 
By slow degrees the head-symptoms abated ; she was free i 
giddiness for days, and the occasional attacks were in a mitigated 
form, and for short intervals only. At the end of two months, AA 
had so far improved, as to be able to enter service as a housemtud. 

Although tlie general cause of this kind of inflammation is B 
usually an attack of scarlet fever, measles, or common cold, this 
affection may follow a blow on the ear or head ; and it is probabla 
that in the following case n blow was the primary cause of the 
disease. 

J. S., aged 35, was admitted under mj care, in the Hospital, ott 
Slay l8t,'1853, complaining of pain in the right ear and dovn the 




ITY OF THE TYMPAKUN 



277 



back, accompanied by faintncss when the nose was blown, or the ear 
was pressed. She stated that when she was ten years old, she 
received a blow on the right ear, sinco which tbiit ear has been deaf. 
Two years ago, discharge took place from the right ear, and baB 
continued. On examination, the membrana tympani was observed 
to have fallen in, and there was a ralvular opening at the lower part, 
through which discharge was forced upon blowing the nose. Regard- 
ing the case as one of long standing disease of the tympanic mucous 
membrane, causing irritation of the brain, I at once ordered a scton 
to be placed in the back of the neck, the effect of which was slowly, 
but entirely, to remove pain from the cars, the head, and the spine. 

The general opinion respecting the mode in which disease pro- 
gresses from the ear to the brain, appears to be that the bone 
becomes carious, the dura mater ulcerates, the arachnoid and the 
pia mator, and ultimately the substance of the brain, participate in 
the disease, as the result of direct extension from the ear. A care- 
ful examination of the poit-nwrfem appcanmces found in some of 
the fatal cases, shows that the dlscasp docs not always advance from 
the car to the brain as the result of continuity ; indeed, in some 
instances, an abscess is developed in the brain without ulceration of 
the mucous membrane of the tympanum, or caries of the bone. It 
would appear that constant irritation in the tympanic cavity, pro- 
duced by chronic inflammation of the mucous mouibrane, with the 
absence of a free outlet for the matter, is sufficient to produce 
an abscess in the substance of the cerebrum. Dr. Abercrombie 
states : There is reason to believe that extensive suppuration within 
the cavity of the tympanum is capable of producing symptoms of 
great urgency, especially if there should be any difficulty of finding 
"an outlet;" but the evidence derived from dissection shows that 
these symptoms of great urgency arc associated with disease of the 
cerebral substance, without the existence of caries of the petrous 
bone. Thus in a case published by Dr. Joseph Williams,* of which 
the following is an abstract, there was no caries of the petrous bone. 

Cffee VII, Ulceration of the tympanic viucotig membratte ; ah»ce»» 
in the gnbtitance of the brain ; patrons hone not carious. — E. B., 
aged 23, not strong, but her health, till about a fortnight before her 
rieath, had been uniformly good : she was then suddenly seized with 
violent headache, and most severe pain in the right car ; chilliness 



* Trcfttin on the Bar. London, 1840. 



278 THE DISEASES OF THE EAR. 

next came on, which in a short time amounted to actual rigors. The 
pain in the ear now increased, and for several hours there was an 
oozing of blood from the meatus. The next daj the discharge be- 
came thin and ichorous ; the febrile symptoms rapidly increased ; 
she fell into a state of semi-stupor, and the discharge became thick, 
fetid, and purulent. She died on the third day after the appearance 
of the acute symptoms. 

Autopsy. — The dura mater was softened, and easily broken down 
over the petrous bone. In the substance of the middle cerebral 
lobe was an abscess containing an ounce of pus, which had a fetid 
odor, was of a dark yellow appearance, and was mixed with serum. 
The abscess itself appeared to be about the size of a five-shilling 
piece. It had penetrated deeply into the substance of the brain, 
and its contents were mixed with blood. The portion of the brain 
surrounding the abscess was soft and very vascular. The surface 
of the petrous bone was of a somewhat dark color, and on sawing 
into it, the inner portion of the petrous bone was found increased in 
vascularity, and even in some parts ulcerated; the secretion was 
fetid and puriform, and the mucous membrane completely destroyed. 
The membrana tympani was ulcerated nearly through, and some of 
the bones of the external ear were destroyed. Dr. Williams adds : 
'^ Dr. Alison has communicated to me a case where abscess was 
found in the brain, consequent upon disease attended with discharge. 
The petrous bone was sound, consequently there was no communica- 
tion between the matter of the ear and that of the brain." 

In other cases, a considerable portion of healthy brain is found 
to exist between the abscess and the petrous bone. For the particu- 
lars of the following case, and for the opportunity of making the dis- 
section, I am indebted to Dr. Merriman. 

Case VIII. Catarrh of the mticous membrane of the tympanunij 
since measles; attack of arachnitis ; death ; petrous bane not carious; 
abscess in the substance of the brain ; adjacent cerebral matter healthy. 
— M. K., a widow, aged 26, of a scrofulous diathesis, and much con- 
fined to the house as a maker of military caps, came under the care 
of Dr. Merriman, at the Westminster General Dispensary, for a 
cough, on the 7th January, 1846. On the 26th, she complained of 
earache on the right side, and then said that she had been subject 
to a discharge from the right ear since an attack of measles when a 
child : the discharge was at times very offensive. Previous to the 
present attack, no pain had ever been felt; but she is said, for 



THE CAVITY OF THE TYMPANCM. 



279 



twelve or Bixteen months to have suffered much from lieadaclies, 
being at times forgetful anil very giddj. She has also fttllen away 
very much. At first, only fomontations wore ordered, which were 
followed by leeches; but without any benefit. The pain greatly 
increased, and was dkscribcd as if, at times, a knife were being 
thrust into the ear; and then, as if there was a sawing outside the 
ear at its edge. During paroxysma of pain the patient screamed 
out suddenly, and then could not open her mouth. On two occa- 
sions a small quantity of discharge was observed, but its appearance 
afforded no relief. When the pain at all relaxed she lay in a partial 
sleep. On the 17th of February site became insensible, but put out 
her tongue when loudly told to do so, and then relapsed into a 
comatose state. She died on the evening of the 17th, twenty-three 
days after the attack of pain had commenced. 

Autopty. — When the skull was sawn through, pus flowed from 
within the dura mater; and upon examination it was found to come 
from an abaccsa which occupied the whole of the upper part of the 
right cerebral hemisphere. The substance of the surrounding brain 
was healthy. The dura mater above the part cut off by the saw 
presented a patch of coagulable lymph, about the size of a four- 
penny piece; lymph was also effused on the surface of the dura 
mater, covering the petrous bone, and a portion of it was detached 
from the bone. Vpon dissection of the ear, the membrana tympani 
was absent; the tympanic mucous membrane, and that of the 
mastoid cells, was thick and soft, and covered by a large quantity 
of caseous, scrofulous matter. The upper tympanic wall was of a 
dark color, extremely thiu, and perforated by numerous blood- 
vessels. The dura mater covering the upper part of the petrous 
bone, and that lining the squamous bone, was very thick and 
detached from the bone, and a large quantity of purulent matter 
was deposited between the dura mater and the arachnoid, The 
arachnoid membrane was highly congested. In some parts the 
purulent matter had passed through the dura mater, and was in 
contact with the hone. The outer surface of the dura mater, 
forming the lateral sinus, was rough where in contact with the in- 
flamed bone ; and the internal surface of the sinus had portions of 
fibrin adhering to it. 

The presence of a portion of healthy brain between the abscess 
and the petrous bone, has induced some observers to conclude that 
abscess in the cerebrum is the primary disease, and affection of the 



THE DISEASES OF THE 



ear the result. The objectioiis to this opiaiou are: Firstly, tiwt 
the cases of abscess in the cerebrum are usually preceded by a long 
standing affection of the ear. Secondly, that the portion of bone 
which becomes carious is far from being the most- dependent part 
of the cerebral fossa. And, thirdly, that although the abscess may 
be very large, the walls of the tympanum only are the real seat of 
disease in the bone. 

The very insidious progress of the disease in its course towards 
the brain has been already adverted to. In some cases no symp- 
tom indicates to the patient that the brain has become affected until 
the sudden appearance of the acute stage; the presence of a di»- 
charge from the ear and a certain amount of deafness are, as thejr 
assure the medical man, the only unpleasant symptoms. Never- 
theless, it does seem to me that, by a careful professional cs^ 
mination of the patient, the early stages of the disease might be 
detected ; for in cases where my suspicious have been aroused by 
the condition of the ear and the inward progress of the disease, I 
have not unfrequently found an unnatural sensibility of the braia 
upon percussing the suspected side of the head. In some cases the 
discharge may take place for a mouth or two, and then disappear 
for a similar period ; where this cessation occurs, however, there is 
usually tenderness in or about the ear. The simple fact of discharge 
occasionally issuing from the ear should induce the medical man to 
make a careful investigation. 

The exciting causes of the acute cerebral symptoms are varioas : 
a blow upon the head, violent exercise, a cold, stimulating applica- 
tions, or any depressing influence, may bring them on. Sometimes 
no exciting cause can he detecled beyond the progress of the clironio' 
affection of tlie ear. 

One of the first symptoms of the disease assuming an acute form 
ia the cessation of the discharge ; this is the result of inflammatory 
action, and it is so commonly associated with the origin of acute 
symptoms, that the stoppage of the discharge has been considered 
OS the cause instead of the effect of acute inflammation ; and medi- 
cal men have been afraid tu stop a discharge from the ear, lest in- 
flammation of the brain should be induced. If this fear were confined 
to the exclusion of all irritating astringents in these cases, it would 
be salutary ; hut when it gives rise to a belief that it is injudicious 
to interfere in any way with a disease of the ear which is slowly 
progressing, and which, if neglected, would probably terminate in 




THE CAVITY 



IE TYMPANUM. 



281 



the death of the patient, it may act very prejudicially. Mr, Wilde, 
in his work on "Aural Surgery," before alluded to, has some inte- 
resting obBervations on this subject. 

Two cases of abscess in the substance of the cerebrum, arising 
from catarrhal inflammation of tlie mucous membrane of the tym- 
panum, have been already described. In that which follows, the 
post-niurtcm examination was attended by me with the late Mr. 
Parish. Death took place from arachuitia, and an abscess was found 
in the middle cerebral lobe; but the cause of the irritation appeared 
to be the presence of scrofulous matter in the tympanum. 

Cate IX, Scrofulous matter in the tympanic cavity; caries of the 
upper wall of the tympanum; arachnitis; abscess in the middle 
cerebral lobe. — Miss II, G., aged 9^, fair and delicate, but not un- 
healthy, had measles when quite a child, though not severely ; since 
the measles, has had an offensive discharge from the left ear, at- 
tended by occasional attacks of pain. On the 5th May, 1845, she 
was seized with symptoms of active fever. She did not complain of 
headache, but when questioned, said there was some uneasiness 
about the vertex. The discharge had ceased. There was constant 
vomiting. Calomel and opening medicines were administered, fol- 
lowed by effervescent salines. On the 7th, she seemed well ; every 
unpleasant symptom had vanished ; her pulse was natural, her 
tongue clean, food was relished, and there was no pain. On the 8th, 
the bad symptoms reappeared. On the 10th, she complained of pain 
in the left ear, which, by degrees, became excruciating to the last 
degree ; she, however, retained her faculties till from twelve to twenty 
hours previous to her death. The only symptoms of derangement 
of the nervous system were, some vomiting and a slight degree of 
paralysis of the muscles on the left side of the face. The remedial 
means employed were leeches, calomel, James's powder, and a little 
opium ; and these were employed freely from the 11th. In spite 
of all efforts, she gradually became comatose ; but even then fre- 
quently shrieked out from pain on the left side of the bead. She 
died at midnight, on the 15th, twelve days after the occurrence of 
the first symptoms. 

Autopsy. — Upon removing the calvaria, the dura mater was 
observed to be red, and its bloodvessels distended. The cavity of 
the arachnoid on the left side contained nearly half an ounce of 
yellow purulent matter; lymph was deposited upon the inferior sur- 
face of the posterior lobe of the left hemisphere. The arachnoid 



282 THE DISEASES OF THE EAR. 

and pia mater covering the inferior surface of the middle lobe on 
the left side, were thick and dark colored over a superficies about 
the size of a sixpence. This thickened portion corresponded with 
an orifice in the dura mater covering the upper surface of the 
petrous bone. In the interior of the left middle cerebral lobe, 
there was an abscess as large as a small hen's egg, in which a 
quantity of dark-colored fetid matter, of a watery consistence, was 
contained. There was no communication between the abscess and 
the cavity of the arachnoid. The dura mater covering the upper 
surface of the petrous bone was three or four times its usual thick- 
ness, and its inner surface darker colored than natural and rough ; 
being in some parts firmly adherent to the bone, and in others 
detached from it. About the centre of the upper surface of the 
petrous bone, the dura mater presented an orifice about a line in 
diameter, directly beneath which was another and smaller one in 
the petrous bone, measuring about a quarter of a line in diameter. 
The latter orifice, and several smaller ones about the size of pin- 
holes, were filled by concrete scrofulous matter, which projected 
from the tympanic cavity. The superior wall of the cerebellar 
corner of the tympanum presented two carious orifices. The tym- 
panic cavity and mastoid cells were completely full of scrofulous 
matter, having the consistence of soft cheese, by which the mastoid 
cells appeared to be much dilated ; the mucous membrane of the 
tympanum was but slightly thicker than natural, and, where orifices 
existed, they appeared to have been produced by atrophy, resulting 
from the pressure of the scrofulous matter rather than from the pro- 
cess of ulceration. The greater part of the substance of the mem- 
brana tympani had been destroyed, and the remaining fibres were 
adherent to the inner wall of the tympanum. 



(/.) ULCERATION OP THE MUCOUS MEMBRANE OF THE TYMPANUM. 

This disease is rarely met with, and its treatment is the same as 
that of chronic catarrhal inflammation. 

The following case, belonging to this class, was supplied to me by 
Mr. Obre, together with the preparation. 

Case I. Scrofulous ulceration of the tympanic mucous membrane; 
destruction of the upper wall of tympanum ; purulent degeneration 
of the middle cerebral lobe. — A young lady, aged 18, of scrofulous 



THE CAVITY OF TUE TYMPANUM. 283 

distbeets, and who was treated by a medical friend, was attacked, 
on November 20th, 1846, with Tever and hjaterical symptoms, un- 
acoompanied by any pain. The following day symptoms of pleuritis 
appeared, accompanied by Bovere pain in the right side of the head. 
It was now ascertained that she had been deaf in the right ear for 
two yeara, and that the deafness was preceded by a fetid discharge. 
Kot withstanding the moat active treatment, the symptoms of cere- 
bral irritation grew worse daily, and death occurred on the ninth 
day of the attack. The patient's memory and intellect were perfect 
np to the hour of her death, which was preceded by epileptic fits. 
There was a very fetid odor about the ear, but no discharge. On 
disKfCtiou, the porioBteum was found detached from the exterior, 
and the dura mater from the interior, of the squamous bone, and 
separated by dark-colored pus. The dura mater on the right side 
of the litjad was gangrenous over a large surface ; and the middle 




Th« Inlcrnal lurfitcs 



lobe of the right heniisphero was in a state of suppuration, being 
principally composed of pus. On careful inspection of the petrous 
bono, the whole of the upper wall of the tympanum was found to 
hare been destroyed by caries; and the tympanic cavity o 



THE DISEASES OF THE EAR. 



cated with that of the cerebrum by an aperture, measuring three- 
quartera of an inch in length, aod a third of an inch in breadlli. 

It thus appears that in some cases the disease of the ear, instead 
of an abscess, produces purulent degeneration of the substance of the 
brain. 

C'ate II. Ulceration of the mucous membrane of the tympanum; 
caries of the hone; partial destruction of the portio dura nerve, and 
softening of the dura mater. — John Cochrane, a laborer, aged 44, 
was admitted under the care of Dr. Kingston, at the Westminster 
Hospital, for consumption, in October, 184f, His history is, that 
twenty-four years previously, di.'icharge took place from the right 
ear, and has continued ever since. He has long been deaf in that 
ear, but has not complained of any head-symptoms. On examining 
the ear the membrana tympani was absent, and the tympanic mucous 
membrane was covered by an opaque discharge like cream. When 
that was removed, the mucous membrane was seen to he thick and 
its surface rugose. The patient died of consumption about a month 
after his admission into the hospital. Some days previous to hJa 
death, there was a paralytic condition of the muscles of the right 
side of the face ; but there was a partial recovery of their action a 
short time previous to death. On dissection, the mucous membrane 
lining the tympanic cavity was found very thick and dark colored, 
excepting at the anterior part, where it had been destroyed by ulce- 
ration. The stapes was absent. At the upper part of the tympanum 
the bone was carious ; the aqueduct of Fallopius was exposed for a 
space of more than a line and a quarter in length, and the portio 
dura nerve, in a soft and ulcerated state, protruded from it. The 
part of the nerve towards the tympanum was gelatiniform in its 
consistence, and extended downwards so as to cover the fenestra 
ovalis. The posterior half of the nerve was' healthy. The dura 
mater covering the petrous hone was thicker than natural ; and a 
small circular portion, about a line and a quarter in diameter, was 
of a dark brown color, and of a pulpy consistence. It was slightly 
raised above the surface of the surrounding membrane, and on being 
touched broke up, and exposed a carious orifice in the bone below 
it. The hone around the orifice was very thin. The brain was not 
diseased. 

In this case there appeared no obstacle to the free escape of the 
discharge, excepting its tenacity and its concretion in the tympaoie 
cavity ; and it is worthy of observation in a practical point of view, 



TflE CAVITY OF THE TYWPANCM. 



285 



that unless the sjriiigo witL warm water be frequently MBed, the 
matter secreted by the mucous membrune of the tympunum ia apt 
to accumulate and solidify, and bo cause a certalu degree of irrita- 
tion in the adjacent parts. 

In the following, which is the last case I shall cite in reference to 
this class of diseases of the tympanum, the disease was evidently of 
a scrofulous character. The mucous membrane of the tympanum 
had ulcerated, and its place was occupied by scrofulous matter, 
The substauce of the brain had also undergone scrofulous degenera- 
tion. 

Case III. Ulceration of the mucous membrane of the left tympa- 
num ; noft-ening and tubercular deposit in the corresponding cerebral 
lobe. — Wm. K., aged 4, was admitted under my care, at the St. 
George's and St. Jamcs'y Dispensary, in March, 1849. He was de- 
scribed as never having had good health, his bowels having always 
been irregular, and bis abdomen tumid. In earliest infancy dis- 
charge of offensive matter took place from the left ear, and has 
never disappeared for more than a, few days at a time. The ear 
appeared tender to the touch, although no pain had been complained 
of. Has suffered from pain in the forehead and eyes for some 
months. 

Three days before my seeing him, he fell down at school in what 
appeared to be a fit, and remained insensible for some minutes. 
Upon his recovery he was found to have lost the use of the muscles 
on the right side of the face and body. When seen by me he was 
in a state of extreme exhaustion, speechless and hemiplegic. On 
the following day he complained of great pain in the left ear and 
the left side of the head, aud there was an abundant, creamy, offen- 
sive discharge from the ear. 

On examination, the whole of the membrana tympani was found 
to have been destroyed, the tympanic mucous membrane had disap- 
peared, and the cavity contained thick, caseous, scrofulous matter. 
The pain in the head and the convulsive fits increased in intensity ; 
he often remained insensible for hours together ; hia strength gra- 
dually declined ; and, in spite of the most active treatment with 
leeches and mercury, he died on the 2l8t of May. 

Autopsy, sixteen hours after death. — The dura mater covering the 
upper surface of the cerebral hemispheres was healthy ; but in the 
substance of the left cerebral hemisphere, above the middle cerebral 
lobe, was a space measuring three inches from behind forwards, an 



286 TSE DISEASES OF THE EAB 

inch anil a bnlf from without inwarile, and an inch from aboTfr ddwa- 
wards, which was much harder than natural, and studded with tuber- 
cles; and between this masa and the lateral ventricle the brain was 
pulpy. In the left lateral vcntriclea was a small quantity of turbid 
aei-um. The dura mater covering the upper surface of the petrous 
bone was more vascular than natural, and on its free surface was a 
patch of blood. The upper wall of the tympanum was dark colored, 




and the thick mucous membrane was seen beneath it. The tympa- 
nic mucous membrane was very thick, and of a dark purple color, 
its vessels being distended. The upper part of the tympanum was 
so filled by this thick membrane, that the scrofulous matter and pus 
were retained by it. The scrofulous matter itself was composed of 
fine granules of epithelial cells, and of very fine crystals, wliich latter 
were stated by Dr. Garrod to consist of phosphate of ammonia and 
magnesia. The stapes was disarticulated from the incus, and the 
ossicles were concealed by the thick mucous membrane. The lower 




OBseouB wall also was thin and of a red color, and presented an orififlA J 
which allowed of a communication between tho tympanum and the 
foaaajugularis. 



THE CAVITY OF THE TYMPANUM. 287 

This case is especially interesting, from the fact that the disease 
had extended downwards to the lower osseous wall, as well as up- 
wards. The lower wall of the tympanum is frequently formed by a 
thin layer of bone, which separates it from the fossa jugularis. In 
many instances this osseous lamina is deficient in parts, and the 
outer surface of the mucous membrane of the tympanum is in con- 
tact with the jugular vein. Disease may thus be propagated from 
the tympanic cavity to the jugular vein. 



CHAPTER XIII. 

THE CAVITY OF THE TYMPANUM {concluded). 

a. BIOIDITY OF THE MUCOUS MEMBRANE — CAUSE OF DEAFNESS IN ADTANCINO TEARS — 
TREATMENT — CASES, b. THE FORMATION OF BANDS OF ADHESION. C. ANCBTL08I8 OF 
THE STAPES TO THE FENESTRA OYALIS — PATHOLOGICAL OBSERVATIONS — ^TREATMENT 
CASES. d. DISCONNECTION OF THE INCUS AND STAPES — PHTSIOLOOICAIi OBSER- 
VATIONS — PATHOLOGICAL OBSERVATIONS — CASES. 

The mucous membrane of the tympanum may be subject to 
chronic inflammation, complicated or not with rheumatism, at any 
period of life, and, if neglected, this is liable to terminate in a rigid 
state of the membrane ; so that the ossicles become bound together 
more firmly than is natural. In advanced years, this rigid condition 
seems to take place without any symptom of inflammation. The 
membrana tympani also partakes of this rigid condition, and, what 
is of far greater importance, the base of the stapes may become 
much more firmly fixed to the border of the fenestra ovalis than is 
natural. As a consequence, the membrane of the fenestra rotunda 
and the fluid of the labyrinth participate in this fixed condition. 
This afiection is less prevalent in the young than in the adult, in 
whom it is liable to occur after repeated attacks of cold, whether 
with pain or not. It is, however, most frequent in persons ad- 
vancing in life, and may, in fact, be considered as the disease which 
causes deafness in advancing years. The generally received opinion 
that in this kind of deafness the nervous system is at fault, is mani- 
festly incorrect, as proved by the symptoms, and by the mode of 
relief found beneficial. 

The diagnosis of this afi'ection is far from being diflScult ; although, 
as will be seen, it offers very little to guide the medical man, except 
the history of the case. Thus, there is very often little or no 
opacity, or even dulness, of the membrana tympani ; the Eustachian 
tube too is pervious, and the air enters naturally. Not unfrequently. 



THE CAVITY OF THE TYMPANUM. 



289 



however, the membraDa tympani shows signs of chronic inflam- 
mation, in hypertrophy and a greater concavity than natural ; while 
the air, when forced into the tympanum, enters it with a dull flap- 
ping sound instead of the normal crackling. Sometimes on forcing 
the air into the cavity very suddenly, a greatly louder crackling 
than is natural is heard ; and the patient occasionally hears better 
for a short time subseqnent to the operation. A symptom of con- 
siderable importaneo in forming a diagnosis, is the peculiar character 
of the deafness. Many patients will most distinctly hear a single 
voice, although low, but are puzzled to hear anything distinctly 
when two or more persons arc speaking ; others hear the voice, but 
cannot discriminate the words ; others again can hear alow conver- 
sation, but cannot follow it when rapid. These symptoms indicate 
that the adapting poioer of the ear, dependent, as already shown, 
upon the ossicles and their muscles, is at fault. But the history of 
the case, showing it to be one of alow hardening of the tympanic 
mucous membrane, together with the absence of all those symptoms 
which render it liable to be confounded with other diseases, as 
nervous deafness, obstruction of the Eustachian tube, kc, are usually 
sufficient to enable an attentive observer to form a correct diagnosis. 

Treatvient. — It is highly important to inquire whether any reme- 
dial measures can be suggested which will tend to diminish a rigid 
state of the mucous membrane, and cdnsequently improve the power 
of hearing. Practical experience induces me to believe that not 
only may the thick membrana tympnni be relieved, but the thick- 
ened mucous membrane be so reduced as to offer but little impedi- 
ment to the function of hearing. 

The moat suitable application for this purpose which has been 
tried by me, is that of a solution of nitrate of silver, of a strength 
varying from half a drachm to a drachm of the salt to an ounce of 
distilled water. Proceeding from the exterior orifice of the meatus 
externus, the passage may be touched to an extent varying from 
one-half to two-thirds of its length every third or fourth day. In 
some cases the membrana tympani also may be washed with a solu- 
tion of this salt of six grains to the ounce. When the noises are 
loud, and the symptoms indicate much congestion in the ear, leeches 
should be applied immediately below, not behind the ears ; and where 
there is irritation of the external tube, an ointment, composed of 
half a drachm of pulvia cantharidia added to as ounce of simple 



ointrnpiit, aDd applied behind the car, either daily or evwy 
day, will be fouDd beneficial. 

The administration of alterative doses of pilula hydrargyri, hj^ 
drargyrum cum creta, or the hjdrargyri bichloridtmi, is very useful' 
but it should always be recollected that these doses ought to be so 
proportioned as not to produce debility or any other unpleasant 
Bymptom; in other words, bo gentle should be the alterative that nft 
sensation should suggest to the patients that they are under a course 
of medicine. 

In addition to the medicines described, patients should be cautioned 
to avoid warm rooms and sitting very near the fire ; daily exercis^ 
and, where possible, on foot, should be taken in the open 
gether with a warm bath every week or ten days. This course of 
treatment has been productive of the greatest advant&go in several 
coses of deafness of a most unpromising character. Some of thv 
cases about to be cited are those of patients who attributeil theit 
failure of hearing to old age. 

The treatment pursued by continental surgeons in cases of rigidity 
of the tympanic mucous membrane, has been the injection of air by 
means of the Eustachian catheter. There can be no doubt that 
porary benefit in these cases sometimes follows the use of the Mr- 
douche, as well as the act of forcing the air into the tympania 
cavity, by the patient holding the nose while he attempts a forcibls 
expiration. But the very temporary character of this benefit, and 
its occurrence in only a few cases does not induce me to recommend 
the performance of an operation ; in fact, a forcible expiration by 
the patient usually answers equally well. On this subject I may 
quote the following judicious remarks from the article on the Dis- 
eases of th? Ear, in the Cyclopredia of Surgery, by Mr. Wharlon 
Jones, — an article characterized, as are all his works, by the most 
careful observation and patient research. He writes: "According 
to Kramer's ' Tabular View of the Frequency and Curability rf 
Diseases of the Ear,' out of three hundred cases of diseases of the 
ear of all kinds, two hundred, in round numbers, required the air- 
douche to assist the diagnosis, but about thirty only were impro- 
vable or curable by it. Of the remaining one hundred and seventy 
about thirty are put down as cured, and about fifty as relieved, by 
the injection of vapors of acetic ether ; this treatment having beea 
continued for months. Of the remainder, eighty were considered 
incurable from the first, and not treated further than was necessary 





TOE CAVITY OF THE TYMPANOM. 



291 



for explotatioii, I suppose ; the rest remained rebellious to treatment. 
Dr. Kramer does not tet! us how permanent his cases were. It will 
be seen from the above statement of the results of Itard's expe- 
rience, and also from what I have'related of my own, that the ad- 
vantage gained is seldom permanent." 

Case I. Rigidity of the tympanic mucous membrane. — The Rev. 
M. M., fct. 70, consulted mc in 1855, on account of an increasing 
duiness of hearing, which caused him much inconvenience, as he 
could not hear general conversation. It had come on very gra^ 
dually, without pain, noises, or any unpleasant sensation, beyond 
that of a feeling of heaviness in the ears. The deafness is increased 
by a cold, but not by fatigiie. On examination, each membrana 
tympani was seen to he less translucent than natural ; and though 
the Eustachian tube was natural, the air entered the tympanic cavity 
in a puff instead of producing a faint crepitation. The treatment 
consisted in keeping up a slight irritation by means of a vesicating 
plaster behind each ear, and in giving the bichloride of mercury in 
doses of one-thirtielh of a grain, using also a stimulating gargle. 
This treatment was continued, with intermission of the mercury, for 
a week at the end of each fortnight, for four months. At the expi- 
ration of that time, the hearing power was greatly improved, and 
the patient wrote to me as follows : — " I have not recovered the 
quick hearing of early life, which a man in his 70th year has no 
right to have ; but I hear comfortably, and I am freed from that 
dunny sensation as if sounds eamo through a damp cloth." 

Ca»e 11. — R. B., Esq., aged 80, in tolerable health, consulted me 
on 29th of March, 1844, on account of deafness in both ears. Ho 
Btated, that three years before, the power of hearing began gra- 
dually to decline in the right ear, and had continued to do so up to 
the time of consulting me : that about six months previously the left 
ear had been similarly affected ; and that his deafness had so much 
increased as to disable him from hearing the voice without the aid 
of a speaking-trumpet. He was unable to assign any cause for the 
deafness. On examination, the membrana tympani in each ear was 
observed to be dull and opalescent ; and although by aid of the 
otoscope the air was heard to pass into the tympanic cavities, yet it 
did 80 with the bubbling, crackling sound, indicating obstruction. 
Two grains of pilula hydrargyri were ordered to be taken every 
night, and a stimulating liniment to be applied around and below 
the ears. This plan having been persevered in for about ihreo 



292 



DISEASES OF TH 




weekp, and Home aliglit. improvement experienced, the patient 
ilirected to take one grain of hydrargyrum cum cretS daily. At the 
end of two months this gentleman recovered Lis hearing, and gave 
up the use of the speaking-trumpet. 

Cane III, — J, P., Esq., aged 64, consulted me in July, 1845. 
During the last four or five years the right ear has been growing 
deaf, and the deafness has now so far advanced as to render the ear 
useless to him. Has been Buffering from a coid for a few days, 
during which there has been a sensation of singing and of vibration 
in the head and ears, accompanied with deafness. In each ear thera 
was a large collection of wax, on the removal of which the symiH 
toms somewhat abated. The membrana tympani of both ears was 
white. Air passed freely into the tympanic cavities. The fiftcentli 
of a grain of hydrargyri bichloridura thrice a day was prescribed, 
and counter-irritation around the ears. In the course of six weeks 
the patient had perfectly recovered. 

Case IV. — Lady R., aged 62, consulted me in December, 1848, 
for a deafness which had come on during the preceding month, and 
gradually increased, till, by the time I saw her, it was requisite to 
sgeak loud and close to the ears. The deafness had first been per- 
ceived after a cold, and was accelerated by an attack of influenia. 
The feeling in the right ear was that of a veil hanging over it. In 
each ear the membrana tympani was white, and air passed freely 
into the tympanic cavities. The treatment pursued consisted in the 
application of a solution of argenti nitras to the outer half of the 
external meatus ; beginning with the strength of half a drachm of 
the salt to an ounce of distilled water, afterwards increasing it to 
double that strength. This course of proceeding, coupled with the 
administration of alterative doses of pilula hydrargyri, effected so 
great an improvement, that in two months this lady had no difficulty 
in hearing in ordinary society. 

Case V. — Mrs. A. T., aged B7, consulted me in April, 1845, 
She stated, that when eight years of age, she fell down on the l^ 
ear, and had been deaf of that ear ever since. About four years 
ago loud internal noises disturbed the right ear, and increased to so 
distressing a degree, that this lady felt as if she were continually 
travelling in a carriage over gravel ; and at times a lond explosion 
would be heard, succeeded hy acute pain. She can scarcely bear 
her own voice, and is obliged to use a trumpet in society. The ears 
aeem to her stopped up with pegs. She attributes this deajness to 




THE CAVITY OF THB TTUPANCM. 



298 



a close attendance in the Bick-room of her husband during a long 

illness. 

Right ear. — Membrana tympani concave, and evidently nearer 
to the promontory than natural ; and the membrane is so white that 
the malleus is not distinguishable. Lvft ear. — Mombrana tympani 
has been entirely removed by ulceration. 

Treatment. — In the first instance leeches were placed imme- 
diately below the ear ; tincture of iodine was applied to the external 
meatus of the right ear ; and three grains of pilula hydrargyri were 
given every night. 

June 3d. — Feels much better ; has less confuflion in the head, 
and more confidence in herself. 

June 15th, — The noises are so much diminished that she is no 
longer troubled by them ; is feeling stronger and better, and the 
hearing improves. 

Ca»e VI. — J. C, Esq., aged C4, consulted me in November, 1844. 
His father became deaf at the age of fifty, and he has a sister deaf. 
About a year ago, he found that he was deaf in the left ear ; might 
have been deaf a longer time ; but at the periotl mentioned, sing- 
ing commenced in the left ear, which has continued ' without inter- 
mission ever since. Occasionally it is much diminished. The noise 
and deafness and are much worse during a cold. The right ear is 
not 80 bad as the left. When he closes the right ear, lie cannot 
bear any sound naturally. 

Right ear. — Membrana tympani opaque, and the handle of the 
malleus only just discernible. When air is forced into the tym- 
panum it can be heard by the otoscope entering it in a series of 
small puffs. After the air has been forced into the tympanum, a 
crackling sensation is experienced. Hearing distance two inches. 

Ze/i ear. — Membrana tj'mpani white; handle of malleus indis- 
cernible ; air enters the tympanum in a short pufi'. Hearing dis- 
tance absolute contact. 

For this gentleman two grains of the pilula hydrargyri were 
prescribed, to be taken every night; and tincture of iodine was 
applied behind the ears. In the course of three months I saw him 
again, and found the hearing decidedly improved ; the noises also 
had diminished. 

Cme VII.— Mrs. R. N., aged 64, consulted me August 2d, 1844. 
For the preceding four or five months deafness had been coming on, 
and had lately so much increased that she finds it difficult to hear any 



294 



THE DISEASES OF THE 



conversation. Has for several years been subject to occasioi 
ness of hearing. The present deafness was apparently produced by 
an attack of cold, which left a sensation of fulness in both e&rs. 
The membrana tympani of each ear is ijaite white. 

Treatment. — One-twentieth of a grain of hydrargyrj bichloridam, 
in conjunction wifh vinura ferri, was administered thrice a day. The 
dose of bichloride was subsequently increased to one-stxteeuth of a 
grain, and a solution of argenti nitrus. half a drachm of the salt to 
an ounce of distilled water, was applied to the outer half of the ex- 
ternal meatus. In the course of three months this patient recovered 
her hearing, and has remained quite well ever since. 



(J.) MEMBRAKOUB BANDS IN THE TYMPANIC CAVITY. 

Membranous bands are formed in every part of the tynipamc 
cavity, connecting together the ossicles, and attaching them to the 
walls of the tympanum and to the membrana tympani. In cases 
where these bauds are lax, it is probable that the movements of the 
ossicles arc not impaired, and that there is no diminution of the 
power of hearing. In the majority of instances, however, these 
membranous bands are so firm and unyielding as to cripple the 
movements of the bones to which they are affixed. On reference 
to the table it will be seen that these membranous bands moat 
usually connect the stapes with the promontory, and thus produce 
one species of anchylosis of that hone. These adhesions originate 
either from the effusion of fibrin from the surface of the membrane, 
and its conversion into a firm and vascular membrane, or from the 
circumstance thatwhen the mucous membrane is much hypertrophied, 
there is an adhesion of the portions of it which are in contact, and 
the neighboring parts are drawn into bands, when the membrane 
subsides to its normal condition. 

Care should be taken to distinguish between bands formed of 
organized membrane, and those which are produced by dried mncus, 
as pointed out by Mr. Ilinton in the paper before alluded to. 

Let me now relate the results of some dissections of cases in 
which these bands were found. 

Cagel. Con»iderahh hardneea of hearing for six ffeart ; handt <^ 
adhegion in the cavity of the tympanum. — Mrs. L. died in December, 
1848, at the age of 87, from a gradual decline of the vital powers. 




THE CAVITT OF ' 



TYMPANUM, 



Until the age of 50, slie had no symptoms of derangement of the 
function of hearing; but about that period she was in the habit of 
taking "cephalic snuff," which she thought produced a buzzing 
sensation in her ears, a symptom which disappeared as soon as the 
use of the snuff was discontiDued. At that period there was no 
sign of deafness ; but about the age of 81, she perceived that the 
sense of hearing was becoming blunted. From that time deafuess 
gradually and very slowly increased, attended now and then with 
noiges in the ears. The deafness would be temporarily increased 
by a cold, but, as that vanished, the usual amount of hearing 
returned. During the last year of her life the disease made but 
little progress, though the deceased was obliged to use a speaking- 
trumpet for the purpose of conversation. It was observed that the 
sense of hearing became much more acute during the last few days 
of her life. This lady took very little exercise during the ten years 
preceding her death, but kept within doors, and sat in a warm 
room the greater part of every day. She was troubled with a 
chronic inflammation of the mucous membrane of the eyelids, 
lachrymal sacs, and nasal ducts. It is worthy of notice that this 
lady had two sisters, one of whom died at the age of 90. She was 
a very active person nearly up to the period of her death, and was 
but slightly deaf. The other sister, at the age of 89, is extremely 
deaf, and has been confined to her room for years. 

Dissection. Rigid car. — The external meatus was dry and de- 
prived of cerumen. The membrana lympani has its fibrous layer 
slightly thickened and white, and is more concave than natural. 
Tympanic cavity. — The mucous membrane appears to be healthy, 




lecting the Ouielsa. 



imdhot thicker than natural, but there are bands of adhesion by 
which the ossicula are connected together and with the walls of the 
tympanum. These bands of adhe^iion may be divided into two dis" 



ASES OF THE 



tinct seta ; one placed between tlie incus and the inner wall of tbe 
tympanum and stapes, and the other connecting the head of the 
malleus and the body of the incus with the external wall of ihe 
tympanum. The firat-nnmed set consists of two portions, of which 
the one, measuring half a line from above downwards, and three- 
quarters of a, line from without inwards, connects the anterior part 
of the long process of the incus with that part of the wall of the 
tympanum which is posterior to the fenestra ovalis. This band is 
connected by several smaller ones to the superior surface of the 
stapes, and also to a fine membrane which connects the two crura 
of the latter bone. These small bands are so firm and so tightly 
etretched between the stapes and the larger band, and between the 
t'lBCus and the inner wall of the tympanum, as to keep the stapes 
I more fixed than natural. There are also adhesions between the 
upper surface of the crura of the stapes and the margin of the fossa 
fenestrie ovalis. The outer portion of this band extends from the 
posterior part of the long process of the incus to the inner wall of 
the tympanum, posterior to that just described: this hand is also 
firm and tense. The second set of adhesions passes from the head 
of the malleus and the body of the incus directly outwards, con- 
necting them with the osseous walls of the tympanum, superior and 
posterior to the attachment of the membrana tympani. It is In- 
teresting to consider what eficct these hands must have had upon 
the ossicula and membrana tympani during life. Those which sur- 
round the stapes and connect it with the fossa fenestrse ovalis, must 
have impeded the movements of the stapes; and those which con- 
nect the long process of the incus with the inner wall of the 





tympanum, by pulling that process inwards, would probably have 
been the means of pressing the stapes towards the vestibular caviiy. 
The effect of the adhesions between the bodies of the malleus and J 




THE CAVITY OT THE TYMPANUM. 



mens, and the outer wall of the tympanum, would seem to have 
been to draw those parts outwards, and, in consequence, their 
inferior extremes inwards. This action upon the malleus is ap- 
parent, and may account for the greater concavity of the membrana 
tjmpani externally; it having been carried inwards with the long 
process of the malleus and being very tense. The bone of the 
stapes is also fixed more firmly than is natural to the margin of the 
fenestra ovalis. The membrane of the fenestra rotunda appears to 
be in a normal state. The membranous labyrinth is healthy ; and 
except that there is rather more black pigment than usual in the 
cochlea of the left ear, tt is in a simitar condition to the right ear, 
and presents adhesions connecting the ossicula. 

Caie II. Membrana tympani very concave externally; banda of 
adhesion connecting the osaicula together aiid to the tympanic walls. — 
Mrs. P. 0., died of gangrena senilis, at the age of 62. She had 
been deaf for a considerable period previous to her death, especially 
in the left ear. 

Hissection. Right ear. — The membrana tyrapani is unusually 
concave externally, and the central part of its internal surface is 
not more than a quarter of a line from the promontory; it is also 
rather opaque in parts, especially at its circumference; and its in- 
ternal layer is white, and slightly hypertrophied. The mucous 
membrane of the tympanic cavity is rather thicker aud more vascular 
than natural, and is very tougji. A firm band of adhesion connects 
the cervix of the malleus with the long process of the incus, and 
another membranous band of adhesion connects the anterior surface 
of the long process of the incus with the promontory and with the 
stapes, which latter bone it completely envelopes. The tensor tym- 
pani muscle is smaller -than natural. 

X-eft ear. — Although the surface of the membrana tympani is 
smooth, it is white around the line of attachment of the malleus ; 
the bloodvessels are enlarged and much distended with blood. The 
membrana tympani is more concave externally than natural. The 
cavitas tympani is three parts filled with a thick, tenacious, white 
mucus, which is partly the cause of the white appearance of the 
membrana tympani, though the inner layer of the membrana tym- 
pani being opaque and white, aids in producing this effect. The 
mucous membrane lining the tympanum is thick and very vascular. 

It is not possible to distinguish, during life, between the cases of 
rigidity of the tympanic mucous membrane, and those of adhesions 



THE DIBEASES OP THE EAR. 



in the tympanic cavity; but as the treatment in both cases is t 
Bame, the distinction is not of much importance. 



(c.) ANCHYLOSIS OF THE STAPES TO THK FENESTRA OVALIS. 

In the published catalogue of the preparations contained in my 
museum, I have described one hundred and thirty-aix specimens of' 
anchylosis of the base of the stapes to the fenestra ovalis : and these 
epecimcDB form the hagiH from which the pathology of this »rticulft> 
tion has been studied. 

In a tabular view of the morbid appearances found in 1149 dis- 
eased ears, published originally in the Tratigactiom of the Royal 
Medical and Ohirurgical Society, and afterwards as an appendix to 
the catalogue of my museum, fifty-three specimens of membraQOUS 
anchylosis arc described, specimens in which the stapes was attached 
more firmly than natural to the circumference of the fenestra ovalis; 
that is to say, upon the stapes being pressed by a fine probe, more 
than usual resistance was offered before the stapes moved. Now, 
in these ca^^cs, no expansion of the base of the stapes, or of the 
articular siu-face of the fenestra ovalis, was observed : and the only 
inference that could be drawn was, that these were cases of partial 
anchylosis of the stapedio-veetibular articulation, resulting from 
rigidity of its capsular ligaments ; and I am disposed to think, that 
this rigidity of the fibrous tissue is one of the earlier and more re- 
mediable stages of anchylosis of this and other articulations, which, 
if allowed to proceed, ends in the formidable pathological conditions 
known under the name of Hieumatic arthritis, and which arc ahont 
to be more particularly described. 

The second morbid change found in this articulation is a simple 
expansion of the articular surfaces, while the structure of the bone 
itself remains, as far as can be ascertained, in a natural state. This 
morbid condition of the articular surfaces was found in forty-nin* 
out of the one hundred and thirty-six cases of anchylosis ; and was 
distinguishable from membranous anchylosis by the greater degree 
of firmness with which the stapes adhered to the fenestra ovalis, and 
by the presence of a distinct tumefaction of one or other articular 
surface, but generally of the stapedial. 

The third pathological condition is that in which the whole of the 
base of the stapes has become bypertrophied, and assumed a oa1o&- 





TUE CAVITY OF THE TYMPANUM 



299 



reous whiteness ; the border being so much enlarged as to be im- 
pacted within the fenestra ovalis with that degree of firmness, that 
the crura are often broken from the base in the attempt to withdraw 




The whole or Ihe Cironmrerenoe of the biife of the SUi»! 
Oiklli, the Crura being deKched. and letm below. 
Oran (magniSed Iwo diiiiae(«r<). 



the latter from the fenestra ovalis. In some instances, this expan- 
sion of the base of the stapes is accompanied by its protrusion into 




IF of the Staprn expanded, and osseons matter thtown ont oronnd It and Iha Crura. 
a. the Btnpea; i, the oaTitj of the Teitlbule (magnifled two diametera). 

the cavity of the vestibule ; slili there appears, even in these cases, 
to be nothing more than hypertrophy and condenBatiou of the normal 



THE DISEASES OF THE 



osseous structure. This morbid coMdition sliows itself In twenty-nine 
specimens. 




The fourth pathological condition is that in which the base of i 
stapes is greatly expanded, aud new osseous matter is thrown out ' 




Expaiislon of tho Vietibulu Sarface of the ArtioulfttioD. (MngniBed two diuueten.) j 
a, Tlifl Ujjper Margin of the Slapsa free ; A, the Lower Murglo of the Stipea uiobj- 

beyond tho nutural limit of the bone, so ns to connect the stapw.J 
with the adjacent parta of the fenestra ovalis ; a morbid condition J 
vhich is seen in twenty-five specimens. 



THE CAVITY OP THE TYMPAND 



301 



The fifth pathological condition la that in which the Htructurc of 
the base of the stapea undergoes little or no alteration : but where 
OBBtfic matter is thrown out at its circumference, and the base is 
thufl partially or wholly anchylosed to the fenestra ovalis. This 
morbid condition is ahown iu twenty-one specimens, in eight of 
■which the lower border only was anchylosed ; there being a distinct 
space between the upper margin of the base and the fenestra 
ovalis : while in thirteen others, the whole circumference of the 
base is 6rmly anchylosed to the fenestra ovalis. 

The »ixtk pathological condition consists iu the expansion of the 
vestibular surface of the articulation, and the effusion of bone around 
the fenestra ovalis, the stapes remaining perfectly healthy ; an ab- 
normal condition which occurred in twelve instances. 

The five morbid conditions last described, comprised in 130 speci- 
mens, may be summarily stated in this form -.-^ — 



Bipnrui 



DIAGNOSIS AND PROONOSIS. 



The diagnosis of this affection is, in the majority of cases, at- 
tended with little difficulty, if the origin and progress of the affec- 
tion be carefully investigated, and the organ be examined with 
sufficient accuracy. The symptoms, in fact, of this class of disease 
are very similar to those occurring in cases of rigidity of the mucons 
membrane, already described. After a certain duration of these symp- 
toms, sometimes for many months, the patient is found to be growing 
gradually deafer and deafer, frcr[uently without any other marked 
symptom, though often there is a feeling of fulness or pressure in 
the ears, or a buzaing sound when laying the head upon the pillow. 
The progress of the affection is at first usually slow ; at intervals of 
two, three, four, or more months, the patient observes the deafness 
to be decidedly on the increase, though mitigated temporarily per- 



THE DISEA 



hapa by his resorting to vorj violent exercise, or hj taking spare 
diet or aperient medicines. If the progress of this affection be left 
unchecked, total deafness resulls, and may lake place at an early 
period of life, as between the ages of twenty and thirty, tbou^ 
commonly it does not happen till a much later period. Sometimes 
the affection advances so far as to produce a certain degree of deaf* 
ness only, us where the patient has to be addressed in a loud voice 
vithin a yard or two of his ear, and then, from some constitutional' 
change, no further progress takes place. An interesting aymptoni 
frequently met with in cases of this disease is the momentary im- 
provement of the hearing produced by the acts of yawning widely, 
or pulling the outer ear, or pressing the tragus hard and quioklj 
against the orifice of the meatus ; each of which actions is followed 
by a temporary relaxation of the membrana tympani and chain of 
ossicles. In the case of yawning, I am disposed to believe that this 
relaxation ia produced by the mechanical action of the chorda tym- 
pani nerve, which, being drawn tight, slightly pulls out the chain 
of ossicles. Another and peculiar symptom, is the effect produced 
by very loud and sudden sounds, as in two of the appended cases. 
In one of these, where, doubtless, the stapes was fixed by the expan- 
sion of its border, a loud scream in the ear at onco restored tho 
hearing by, as it would seem, suddenly releasing the bone ; a resto- 
ration which lasted for several days, until, in fact, the two again, 
became fixed : in the other, a very loud sound of bagpipes in the 
patient's hall, where he was sitting, so increased his deafness, that 
his friends were obliged temporarily to use a slate and pencil to 
communicate with him. This increase of deafness also disappeared, 
and the patient recovered his previous amount of hearing. 

A third interesting and very common symptom of the early stages 
of anchylosis of the stapes, is the loss of what I am in the habit of 
calling the adapting power of the organ. Thus the patient will hear 
perfectly a single distinct voice, but a second voice intermingling, 
completely disables him from hearing either ; he having lost the 
power of rapidly adjusting his ear to suit the sound of the voice of 
the person immediately addressing him to the exclusion of that of 
the other. Yet another striking symptom of the early stages of the 
affection, is the necessity of exercising an act of sustained volition, 
in order to catch the sound of a voice, which ceases to be perceptible 
as soon as the effect is relaxed. It has, indeed, happened to me to 
receive patients whose complaint consisted not in being dull of boar' 



THE CAVITY OF TUE TYMPANUM. 303 

ing, since they could hear evei'jthing said in a room, but in not 
being able to do this without a prolonged effort of attention, the 
fatigue of which soon became intolerable. This latter condition b, 
of course, perfectly explicable, from the more or less rigidity of the 
chain of bones in this disease, and the muscular effort consequently 
required to move it and keep it in constant motion. 

Another symptom, and one certainly characteristic of the later 
stages of this affection, but which it is not in my power to deny may 
not also be present in another diseaee of the ear, is the immense 
improvement to the liearbg which attends the patient's travelling in 
I a carriage over a bard road, by which considerable vibration is com- 
municated to his body, — a vibration that doubtless in a degree 
shakes the chain of bones, and imparts to them a kind of vibratory 
movement, which permits the muscles, while it lasts, so to act on 
these bones as to restore more or less of their proper functions in 
adjusting the pressure on the labyrinth. 

On examining the patient, there is usually abundant evidence of 
the rheumatic or gouty diathesis having been or being present, such 
as congestion or tumefaction of the nasal and faucial raucous mem- 
branes, and, in addition, hypertrophy of the tonsils in young per- 
sons. On inspecting advanced cases, there is usually an absence of 
cerumen from the external meatus, the result of the congestion of 
this part of the organ, of which tlie membranous meatus presents 
most characteristic symptoms, in being red and so swollen as gene- 
rally to have lost its oval form and to have become, in parts, con- 
stricted. Thus the upper half of the tube may retain its normal 
size and shape, while the lower may be reduced to a narrow fissure 
only one-half or one-third of its proper dimensions. Sometimes this 
diminution of the calibre of the meatus arises from a bulging of the 
bone forming the walls, so as to become a convex protuberance; in 
other instances, these osseous protuberances are so prominent as to 
gain the name of tumors, and as such they have been described in 
treating of the meatus. 

The dermis covering this bone is weually of a deep red color ; in- 
deed, as a rule, the dei'moid meatus is highly congested in cases of 
gouty and rheumatic affections of the ear. The condition of the 
mevibrana tyntpani does not afford much aid in forming a diagnosis, 
though as a general rule, to which there are many exceptions, it is 
somewhat more opaque, and its surface duller than natural. Often 
it is very opaque, and white as parchment, and not unfrequcntly it 



804 



ASES OP THE EAR. 



exhibits patches of opacity in different parts. Occasionally 1 
membrane is more concaye externally tlian is natural. In advanced^ 
cases, like those where the base of the stapes has become fixed, tfcn 
membrana tympani is rigid. The presence of this rigidity is, how 
ever, difficult to ascertain by simple pressure on the surface ; but 
its existence may be proved by the use of the otoscope, while 1 
patient either swallows with closed nostrils, or forces the air inW 
the tympanic cavity by blowing the nose forcibly, the noee ai 
mouth being at the same time closed. In each of these acts the a 
is heard to enter the tympanic cavity, for the Eustadiian tube q 
these instances is usually open ; but in place of the fine cracklini 
sound elicited by these operations, when performed on a healthy earj 
a flapping, or coarse crackling, is heard, produced by the air striking 
against the inner surface of the unyielding or tense drum. A yet 
further symptom of this disease is, that the patient commonly bean 
better in proportion to the loudness of the speaker's voice ; wherea^ 
in cases of debility of the nervous apparatus of the ear, it is not tho 
loud voice, but that which is peculiarly modulated which is heard 
the best, occasionally even when as low as a whisper. In additio 
to the foregoing symptoms, the existence of anchylosis of the stapM 
may be diagnosed by a careful attention to the causes producing it, 
and to the stages of its progress, which offer so marked a contrasl) 
to cases of debility of the nervous apparatus, with which cases ( 
anchylosis of the stapes may, doubtless, otherwise be confounded. 

With regard to the prognoiit, it may be laid down as a general 
rule, that so long as the affection depends upon rigidity of the liga- 
ments, or upon a slight expansion of the basis of the stapes (and the 
surgeon can judge of the existence of these conditions during life 
by the symptoms being but little advanced), then there is every prosr 
pect that considerable amehoratiun may be effected, and the patient, 
in fact, bo enabled to hear without any inconvenience, for expcrienoft 
has taught me that a rigid ligament may be relaxed, and an expanded: 
bone be reduced in size. I may even venture on the further statd' 
ment, that, judging from the visible diminution of the bony tumoro; 
in the external meatus under the influence of remedial measures, taii, 
taking into account also the decided improvement which at time* 
takes place in cases where, from the symptoms, there was every 
reason to believe that the stapes or vestibule had become aimilarlj 
expanded, there can be but little doubt that, even in the more ad- 
vanced stages of anchylosis by expansion, some benefit can be ob>. 





CAVITY OF ' 



[IE TYMPANUM. 



tained by the use of remedies which shall cause the offu8e<l matter 
to be absorbed. The more hopeless cases are those in which the op- 
posing articular surfaces of the stapes and vestibule are united by 
ossific matter ; and at present I am unaware of any means by which 
they can be diagnosed and discriminated from cases of anchylosis by 
expansion of the articular surfaces. 

Treatment. — The treatment in these cases differs in no essential 
respect from that recommended for cases of rigidity of the fihro- 
mucous membrane. 

Case I, — Mr. W., aged 4T, consulted me, in the year 1848, on 
account of the stiite of bis health, which was greatly impaired by at- 
tacks of rbeumatic gout and congestion of the liver. When I saw 
him, he was so deaf that he required to be loudly spoken to, within 
the distance of a yard from bis head. His habits were far from 
being temperate, ns he indulged freely in alcoholic drinks. The his- 
tory of his deafness was, that many years previously he had gradu- 
ally become dull of hearing, and that this dulness had increased 
slowly up to the period of my seeing him. The only occasion Upon 
which be had been temporarily benefited, was on the removal of a large 
mass of cerumen from tho meatus. I did not examine the ears, as 
I was not consulted on account of the deafness ; but this omission is 
supplied by the particulars of the post-mortem inspection. After 
having known him for a few years, he die<l from an attack of inflam- 
mation of the lungs. 

Disieetion. Right ear. — The meatus externus was somewhat con- 
tracted, the lower part being rough, and the surface irregular. The 
memhrana tympani was thicker, and more opaque and rigid than 
natural ; the chain of ossicles formed so solid a bridge between the 
membrana tympani and the vestibule, that considerable pressure on 
the handle of the malleus at the outer extremity of this bridge was ■ 
requisite to produce the slightest movement of the chain. In the 
lower part of the tympanic cavity, a white deposit adhered to the 
surface of the bone, and was so closely incorporated with the fibro- 
mucous membrane, aa to render it difficult to pronounce whether it 
was in the substance of, or below the membrane. The base of the 
stapes was somewhat expanded, and its circumference was perfectly 
snchylosed to the fenestra ovalis. This anchylosis was partly effected 
by the expansion of the bone of the stapes, and partly by the effusion 
or prolongation from it, especially at the posterior part, of hard white 
matter. 



THE DISEASES OF THE EAR. 



Left ear. — The meatua extemus was contracted, presentJDg at tH 
posterior part a bulging of bone, and at its inferior part being very- 
narrow. The membrana tyuipaiu was opaque, and the chal 
bones as rigid as in tbe right car. Tho head of the malleus pr*> 
sented small nodosities, similar to those on the heads of other bontu 
affected with rheumatic gout. Tbe stapes was perfectly ancbylosodi 
to the fenestra ovalis by the expansion of its base, and by the pre- 
sence of a large quantity of hard white matter which surrounded iti 
The cavity of the vestibule contained also a great deal of wbiMt 
matter, similar to that in the right tympanic cavity. 

In another case, somewhat analogous in its morbid condition t 
the foregoing, and in which the deafness and anchylosis were eqoally 
complete, the patient died with consumption under the care of De^ 
Sibson, in St. Mary's Hospital, at the early age of 20, clearly ahow* 
ing that this affection is not necessarily un accompaniment of adr 
vancing years. 

Case II. — Mr. L. J., aged 90, in good health, except that be sii& 
fered from attacks of gout, often complicated witb rbeumatisi 
About the age of 40, he found a dulness of hearing gradually conH 
ing on, which as gradually increased, until, at tbe time I saw h 
he could only hear the voice when loudly spoken to close to the hei 
This gentleman had no desire for any treatment to be pursued, 
I merely diagnosed tbe affection from the history of the casG,-< 
alow, insidious progress, the absence of all symptoms of nenronl 
debility, and the attacks of gout with which the patient was troablocL 
My opinion, thus formed, was that the cause of the dcafnesa wa( 
anchylosis of tbe stapes ; an opinion that I expressed to his medica 
and other friends. He died, some years after my first seeing ii 
, of gouty inflammation of the bladder, and the opportunity wai 
afforded me of carefully dissecting both petrous bones. 

Right ear. — Meatus externus. At the posterior and upper f 
there was a distinct, smooth, and rounded projection of the boa^ 
which extends obliquely from without and below, inwards and up*! 
wards, and is continuous with the rough scabrous portion of bontf 
which forms the lower part of the meatus e.xternus at its orifici!, an! 
is quite distinct from the mastoid portion of the bone. This p 
jection measures about three lines from above downwards. At t 
upper part of the meatus the bone is rough and hypertrophied. 

The membrana tympani was more concave externally, and mucli 
thicker and more opaque than natural. It was so rigid that pressnte 




THE CAVITY OF THE TYMPANUM. 



807 



upon the outer surface of the malleus ty tneaus of a fine probe waa 
not followed by any movement of the chain of bones. Upon laying 
open the tympanic cavity and pressing upon the stapes, this hone 
was found to be so compactly attached to the inner wall of the tym- 
panum, that upon pressure there was not the slightest degree of 
movement. A broad membranous quadrilateral band entirely tilled 
the space between the long process of the incus, the internul wall, 
the stapes, and the posterior wall of the tympanum. On laying 
open the vestibule, the base of the stapes was observed to be of a 
white calcareous aspect, and perfectly united to the circumference 
of the fenestra ovalis by calcareous matter. The membrane of the 
fenestra rotunda appeared to be healthy, except that it was, if any- 
thing, slightly thicker than natural. 

Ltfi ear. — The meatus externus presented a bulging similar in 
shape and direction to that in the right ear, though somewhat larger. 
The membrana tympani was thicker and more rigid than natural, 
but not more concave externally than usual. The difference in the 
degree of concavity of this membrane in the two ears was so decided, 
that the inner surface of its central part, in the right ear, was one- 
third nearer to the inner wall of the tympanum than it was in the 
left ear. The stapes was fii-mly fixed, and its base, when the ves- 
tibule was opened, was found to be- e."tpanded and completely anchy- 
losed to the fenestra ovalis. 

Case III, — Mr. T. L. J., aged 50, of a gouty diathesis, the son 
of the above patient, consulteti me, in 1852, on account of gradually 
increasing deafness. When I saw him, he had to be loudly spoken 
to within the distance of a yard of tlie head. He stated that the 
deafness had come on very gradually without any pain or uneasy 
feeling in the ears, and that no relief was ever experienced except 
from taking long walks, and perspiring very copiously. On exam- 
ination, the membrana tympani in each ear was somewhat opaque, 
and the Eustachian tube pervious ; the air entering in a loud puff. 
The history of the case, and its similarity to that of the father, 
made me sure that the cause of deafness was anchylosis of the stapes. 
I laid down certain rules to be carried out, but on account of the 
sedentary nature of the patient's occupation, they could not be ob- 
served; attacks of gout became more frequent, and total deafness 
ensued. 

Case IV. — Mr. N. C, aged 60, a man of intemperate 1 
gradually became deaf at the age of 24. The deafness sloi 



308 



THE DISEA 



OF THE EAR. 



creased to the day of hie death, which took place at the age of 
from ou attack of bronchitis. There was hereditary deafncBS in ttua 
gentleman's family, several sisters and brothers becoming slowly 
deaf about the same age as did this patient. For some time previoiu 
to his death, the patient's right ear was useless, but, by means of » 
trumpet, he could manage to bear loud conversation addreBsed ta- 
him in the left. 

Digseetion of right ear. — (This dissection was m&de by Mr. A.' 
Nopper, who kindly forwarded to me the specimen and his notea.)' 
Membrana tympani more opaq^ue than natural. Numerous transp^^ 
rent, membranous bands traverse the tympanic cavity. The ossicle* 
were in a healthy state, with exception of the stapes, the crura of 
which had disappeared.' The fenestra oralis was closed by the ban. 
of the stapes, which projected slightly into the cavity of the vesti- 
bule. In the vestibular cavity surrounding the fenestra ovalis, vaa 
a white mass of bone, which formed an annular protuberance around' 
the interior two-thirds of the fenestra ovalis. 

Case V. Partial anchyloeii of the stapcit temporarily cured hjf thM 
effect of a hud shout in the ear. — The Rev. L, D., aged between 50 
and 60, saw me in the year 1856, but not on account of his deaf- 
ness, for which he did not seek advice ; I, however, was able to gleaa 
the following interesting details of his case. The general healtli of 
this gentleman was good, with the exception of attacks of indiges- 
tion and rheumatism, which caused him great inconvenience. In a 
letter to me, he says, " I have had rheumatism in the shoulder-joio^ 
which I always walked off, the pain becoming much aggravated as I 
got warmer, but being always at last driven out. I suffered for some 
weeks, three winters ago, from extreme weakness in both ankle- 
joints, so that I could scarcely go about my parish work. My 
friends assured me that it was the beginning of creeping paralysis, 
but I was sure that the stomach was the enemy. My work must be 
done, and I gradually walked my legs back into use." Deafness in 
the right ear appeared to have come on suddenly a few years before 
my seeing the patient, when the left ear was puzzled to know the 
direction of sounds. "I had no conception," he writes, "whence 
sounds came, until by degrees the left ear learnt to put sounds into 
their right places, or ralhor to settle the place of the cause of 



' It is probabli) that tfai crarii of tlio sCupcB hftil bcc 
i« ia the Mt of diuecting the em-. 



dcnUll; discdimcctsd trom tba 





THE CAVITY OF THE TYMPANOM. 309 

sound." No treatment was adopted, and the patient for some years 
remained in the same condition, the left ear being uselesB, or nearly 
so, and the right remaining tolerably perfect. In the year 1856, 
while this gentleman waa superintending his Sunday-school, he was 
called upon to seize a boy who was endeavoring to bite his teacher, 
when, to use the clergyman's own words, " he (the boy) sent Huch a 
yell into my right ear, that 1 heard not only the yell, but for some 
days I heard all other sounds most distinctly, when it, the hearing, 
again relapsed, and my left ear had again to learn ita duties." From 
the history and examination of this case, I have no doubt that the 
affection consisted of rheumatic disease of the a tapedio- vestibular 
articulation, and that the morbid condition waa no other than that 
peculiar expansion of the base of the stapes so frequently adverted 
to. The effect of the loud acream waa doubtless to release the stapes 
for a time, ao as to allow of its movement by its muscles. It may 
here be added, that in another patient who was under my care for 
some time for deafness produced by rheumatism of the ears, an ex- 
actly opposite effect, viz., complete deafness, was temporarily pro- 
duced by a sudden loud sound. This gentleman was quite deaf in 
one ear, but with the other heard a loud voice, when distinctly 
spoken, at a short distance from him. In this condition he waa 
subjected to the sudden shrill sound of bagpipes played in the hall 
where he aat, by which he was at once rendered too deaf to hear the 
human voice, and all communications to him were obliged to be in 
writing. This increased deafness lasted for several days, and then 
the ear recovered the hearing power it possessed previous to the ac- 
cident. There appears to be great probability that in the latter 
case the cause of the increased deafness was, that the stapes were 
driven inwards and held tight by the fenestra ovalis, and that the 
return of the hearing power was due to the release of the stapes. 



{(i.) DISCONSECTIOS OF TQE INCUS AND STAPBB. 

An affection of the ear directly opposite to rigidity of the chain 
of bones sometimes takes place, and this consists in the disconnec- 
tion of the incus and stapes. I will preface my account of this 
affection by making some physiological observations bearing on the 
subject. 

Physiological Obaervationt. — The opinion usually entertajiied is, 



310 



THE DISEASES OF THE EAR. 



that two channels are requisite for the transmission of scmorons tm- 
dulatione tr> the labyrinth from the membrana tympani; one channel 
being the air in the tympanic cavity, which conducts the undijlationa 
to the membrane of the ftinestra rotunda and the cochlea ; the other 
channel being the chain of ossicles, which conducts the nndnlationft 
to the vestibule. 

That this opinion is not universally received is apparent from the 
following quotation from an authority highly deserving of attention, 
Mr. Wharton Jones. He saya : — " Some physiologists assert tiai 
the sonorous undulations are comninnicated from the mcmbrani 
tympani to the ossicles, and through them conducted to the vestibnlar 
fenestra ; others suppose the undulations to bo propagated merely 
through the air in the cavity of the tympanum, to the membrane of 
the fenestra rotunda; the ossicles and their muscles serving tlw 
purpose of regulating the tension of the niemhrana tympani, the 
membrane of the vestibular fenestra, together with the memhranona 
labyrinth. A combination of the two views is most generally rfr 
ceived. However well founded the view may be that sound is pro- 
pagated through the chain of small bones, the circumstance that 
some degree of hearing may jiersiat along with loss partial or t 
pleto of the membrana tympani. and of the malleus and incus, is t 
conclusive proof that sound may be conveyed through the fenestrs 
to the labyrinth, by the vibrations of the air in the tympanum alone. 
It would appear also, that the integrity of one fenestra may ssffiefl 
for the exercise of hearing."' 

Mr. Brooke, whose views on questions of experimental science 
worthy of the fullest consideration, has published his reasons 
believing that it is not possible for the sonorous undulations to M 
conducted to the labyrinth by the chain of hones. 

He says : " I'he transmission of sound cannot take place througli 
the ossicula, as it was formerly supposed, inasmuch aa the pl&ne Ml 
which the crura of the stapes lie, is exactly perpendicular to the 
plane passing through the manubrium of the malleus and long leg 
of the incus ; and consequently, the vibrations passing through theU 
would be almost entirely intercepted by the stapes. And. more< 
it appears essential that the transmission of vibrations through thC 
chain of ossicula should be prevented ; for aa the velocity with whicb 
sound is transmitted through solids, such as hone, so very far e) 

Article, " Diasucs of Eu uid Hnuiug, " p. U. 




THE CAVITY 



OF THE TTMPAKD 



311 



ceeds the velocity in air, if the same undulations reach the labyrinth 
through this channel, and through the channel previously described 
(the au- in the tympanum), they would reach in different times, and 
constant interference would be produced."' 

Although Mr. Brooke has thus confidently expressed his opinion 
that "the transmission of sound cnnnot take place through the 
oasicula," his statement, unsupported by experimenta, and obser- 
vations, docs not seem to have induced writers on the physiology of 
the ear to adopt his conclusions. Thus Dr. Carpenter, in the latest 
edition of his Unman Physiology, Jiaving referred to Mr. Brooke's 
paper, says : — " From what has been stated, it is evident that 
aonorouB undulations in the air will be propagated to the fluid con- 
tained in the labyrinth through the tympanum, the chain of bones, 
and the membrane of the fenestra ovalU to which the stapes is 
attached without any loss, but rather an increase of intensity."* 

Indeed, with a consciousness of the wonderful accuracy of M. 
Savurt's experiments in acoustics, it appears impossible, without fur- 
ther experiment, to disbelieve the assertion he made in the following 
quotation from his writings : — " Les vibrations de la membrane 
se communiquent sans alt<!ration au labyrinthe par le moycn des 
osselets, comme lea vibrations de la table superieure d'un instru- 
ment cumtnuniquent it la table inferieurc par le moyen de I'&me."' 

But supposing with Savart, that under ordinary circumstances 
sonorous undulations are conducted to the labyrinth by the chain of 
ossicles, is it also possible, under certain conditions, for the function 
of hearing to be carried on without the aid of these bones t Mr. 
Wharton Jones has answered this question in the affirmative, as he 
says, that "the integrity of one fenestra may suffice for the exer- 
cise of hearing;" and Sir J. Herschel inclines to the same opinion. 
He says : " These bones form a kind of chain, and no doubt vibra- 
tions excited'in the tympanum by vibrating air, as in the experi- 
ments above detailed, are somehow or other propagated forward 
through these ; but they are so far from being essential to hearmg, 
that when the tympanum is destroyed, and the chain in consequence 
hangs loose, deafness does not follow."' 



■ Report ot a Lectars 
' P»g« 733. 

' Rcchfrcbi's Bur loi Usages da la 
Jonro&l ds Phyniolngig. Par F. Maji 
' Bnejila|H«diii Hitrapoliliuift. Arlielf, "Sound," p. SIO. 



kt the Rejul Inititntion : LancH, \U3. p. 38n. 

Membrane du Tjmiuin, et de rOreUls aztcnie. 



THE DISEASES OF THE EAR. 



Mj object at present is to attempt to ascertain, — 

Firstly-, wlictber eouoroua uniiutatlons from tbe external mestiu 
can reach the labyrinth without the agency of the ossicles; and, 

Secondli/, whether the chain of ossicles can conduct sonorous un- 
dulations to the labyrinth. 

Firstly. Can sonoroun undulation* reach the labyrinth from th» 
external meatus without the agency of the ossicles f 

There can, I tliink, be no doubt but tbat the malleus and iDcufl,' 
and even the crura of the stapes, can be removed without the pro- 
duction of any very serious detriment to the hearing, but there is 
no well-authenticated case in which the base of the stapes Las been 
removed in which total deafness did not ensue, but this dea&i 
must doubtless be attributed to tbo removal of the fluid of the labj 
rinth at the time the stapes was withdrawn, 

But what is the effect of a. 6xed condition of the base of tlie 
stapes? Now it happens that bony anchylosis of the base of the. 
stapes to the margin of the fenestra ovalis is by no means a rare 
morbid condition, and I have had several opportunities of seeing 
patients with this affection during life, watching their symptotDS^- 
and subsequently dissecting the organ. The result of my observa- 
tions is to demonstrate that simple bony coalescence of the base of 
the stapes to the wall of the vestibule is productive of so high a 
degree of deafness, that the sonorous undulations could reach the 
nerve only by passing through the walls of the cmuium ; and thi*' 
statement accords with that of Dr. Pnppcnheim, who found merely 
" some degree of hearing" in a similar case. It may possibly be' 
argued tbat the deafness occurring in cases of anchylosis of the 
stapes to the fenestra ovalis, may be accounted for by the fixed con- 
dition of the mevibrana fenestras rotundfs whieh necessarily results, 
but I think it is palpable that tbe mere incapacity of this membranO' 
to alter its state of tension would not be sufGcient to account for 
the high degree of deafness to sounds {acute equally with the bass) 
which characterized the whole of the cases that have fallen under 
my observation. It may however be asked, is it not possible for 
sonorous undulations to reach the labyrinth without the aid of the 
stapes, since the function of hearing is but slightly impeded by the 
removal of the incus, and when consequently no vibrations can reach 
the stapes, except through the air in the tympanum ? It seems in- 
deed to have been assumed, tbat when the stapes is thus detached 
from the incus, it cannot receive vibrations from the air externally 




CAVITY OF THE TYMPANUM. 



313 



and cooduct them to the vestibule ; what grounds there exii!t for this 
conclusion will be seen from the following experiments. 

That solid bodies are capable of being throi^Ti into a state of vibra- 
tion by the agency of sonorous vibrations existing in, and commu- 
nicated by, the air, is a fact too well known to require demonstra- 
tion ; but the following experiments show how far the solid stapes, 
when isolated from the incus, may possibly receive vibrations from 
the air and conduct them to the labyrinth. 

Experiment. — The ears having been closed, a. piece of wood, five 
inches long and half an inch, in diameter, was held between the teeth, 
and a vibrating tuning-fork, C, having been brought within the 
eighth of an inch of its free extremity, was distinctly heard, and it 
continued to be heard for between five and six seconds. 

Experiment. — One end of the piece of wood used in the previous 
experiment being pressed gently against the outer surface of the 
tragus, BO as just to close the meatus, a vibrating tuning-fork, C, 
placed within a quarter of an inch from the free extremity, was 
heard very distinctly at first, and it did not cease to be heard for 
fifteen seconds. 

Experiment. — Three portions of wood, having the same length 
and thickness as those used in the aliove experiments, were glued 
together HO as to form a triangle having somewhat the shape of the 
stapes. The base of this triangle being placed against the outer 
surface of the tragus ao as to close the meatus, the tuning-fork, C, 
vibrating within a quarter of an inch from the free apex, was heard 
for twelve seconds. 

From the above observations and experiments, I think it may be 
reasonably inferred (hat the stapes, even when detached from the 
otsiclen, if free to move in the fenestra ovalis, will receive lonoroug 
undulations from the air in the tympanic cavity, and will conduct 
them to the labyrinth,^ and that there is no evidence that sonorout 
undulations can reach the labyrinth from the external meatus without 
the agency of at least one of the ossicles, viz., the stapes. 

I shall proceed to inquire, in the second place, whether the chaio 
of ossicles can conduct sonorous undulations to the labyrinth. 

In this second part of the inquiry, I shall endeavor to determine, 



■ Th« rwult of (hsei 



■alt accords vith. Ihe faot I have 
1 rffluiont that the pslient wna not auppojed lo 
diflcimcy of bearing pawf r, haa been found 



niMl, of thB itapu from tha inoni. 



list with Isolation, apparrotly conge- 



314 



OP THE KA». 



a. How far the sonorous undulations excited in the mombn 
tympani are intercepted in the chain of ossicles bj " the plane in 
which the crura of the stapes lie, being exactly perpendicular to the,' 
plane passing through the manubrium of the malleus and the long 
leg of the incus;" and 

b. To what extent the articulations of the chain of bones impeds 
the passage of these undulations. 

(a.) To what extent are these vibrations, excited in the Tnembramm 
tympani, arraied by the variation in the plane of the chain of osstclea. 

After M. Savart's conclusive experiments, repeated and vcrifi 
by BO many subsequent observers, it is needless for me to point oal 
how freely sonorous undulations excited in the air, are communi> 
cated to a membrane like that forming the membrana tympatti; 
how fully they are conducted from a stretched membrane, like thfl 
membrana tympani, to a solid attached to this membrane like thft 
malleus, and free to oscillate. Assuming, therefore, that the vibn^ 
tions reach the malleus, I will proceed to examine how far they srt 
conducted through it and the other ossicles. 

Experiment. — Three pieces of wood, each five inches in Icngti 
and half an inch thick, were glued together so as to represent tlii 
planes of the three bones of the ear ; while three other portions wen 
glued together end to end, foiming a straight rod. A watch Ti 
placed at one end of the straight rod, while the other end was •}>> 
plied against the tragus of the ear, which it pressed firmly iuwardl 
80 as to close the meatus completely and to exclude sounds from 
entering the car by it. The result was, that the watch was faearA 
nearly as distinctly as when it was placed in contact with the oar.' 
When a similar experiment was performed with the angiUar piece of 
wood representing the chain of bones, the watch was still heard, but 
less distinctly. 

Experiment. — ^A tuning-fork, 0', being made to vibrate, woa phwted 
in contact with one extremity of the angular piece of wood, the other 
being placed against the tragus of the ear; and when the straight 
portion was similarly used, it was found, as in the Farmer Gxpen!- 
ment, that the sound was decidedly less loud when heard tbrongb 
the angular than through the straight portion ; and after the sound; 
had altogether ceased to be heard through the angular portion, the 
same tuning-fork was heard for about three seconds, when the straight 
piece was substituted. 

Finding that there existed some little difficulty in exercising tbfr 




same amount of prcsaurc on the tragus of the ear in eacti experiment, 
and considering that a variation in the amount of pressure might 
cause the air in the meatus to assum<^ difftTeut degrees of density, I 
had recourse to tlio teeth as a medium for the transmission of the 
sound. I found that a solid placed in contact with the teeth of the 
lower jaw conducted vibrations with rather greater facility than when 
in contact with those of the upper jiiw, 'and I therefore adopted the 
plan of holding the conducting body between the teeth. 

Erperimtnt. — A tuning-fork, C, was placed at one extremity of 
the angular piece of wood, the other extremity being held between 
tho toeth ; the fork was at first heard very distinctly, and when this 
80und could no longer be distinguished, the straight piece was sub- 
stituted, and it was again heard for the spaco of two seconds. 

Experiment. — Instead of the horiKontal portion of wood repre- 
senting the stapes, three portions of the same size were made into a 
triangle, and this was glued to the anterior surface of the inferior 
extremity of the piece representing the incus ; the last experiment 
was repeated, with the substitution of this apparatus for the angular 
portion, and with very nearly the same result, viz., the fork was 
heard through the straight piece about three seconds after it had 
ceased to be heard by the apparatus representing the chain of bones. 

Experiment. — A piece of iron wire eighteen inches long and about 
two lines in diameter, was bent so as to represent the different planes 
of the chain of ossicles of the human ear ; the tuning-fork, C, was 
placed at one extremity, while the other was held between the teeth. 
The sound was heard very distinctly at first, and when it ceased to 
be heard, a straight portion of the same length was substituted, 
through which the tuning-fork was heard for three seconds. 

Experiments. — A piece of very thin paper was gummed over one 
end of a glass tube three inches in diameter, To the outer surface 
of this paper a model of the ossicula, similar to the one used in a 
previous experiment, was glued. A vibrating tuning-fork, C, being 
placed in the interior of the tube and within a quarter of an inch of 
the paper, the end of the chain representing the base of the stapes 
was placed between the teeth ; the sound was heard distinctly, and 
it continued to be heard for ten seconds. The sound of the tuning- 
fork, C", was heard for twenty seconds. 

The results of these erperiments appear to indicate that the passage 
of sonorous undulations is somewhat, but only slightly, impeded by 
the variation of the plane in which the otsiclea are placed. 



816 



THE DISEASES OF THE EAR, 



I proceed, secondly, to consider the effect of the articiilfttioia 
between the ossicles, upon the passage of sonorous imdolations I 
througli them. 

The articulating surfaces of the small hones of the ear are usually I 
described as being incrusted by cartilage, Khich is covered with sy-l 
novial membrane. Professor KolHker, speaking of these bonee, I 
says, "Their articulations and ligaments resemble in miniatursl 
those of other similar organs in all respects, even down to the carti>l 
laginous layer, consisting of scarcely more than a single stratum."* ] 

Before proceeding with the inquiry concerning the passage of] 
sonorous undulations through the chain of bones, it is desirable to J 
consider carefully the structure of their articulations. 

They may be considered as four in number, viz. ; — 

1. The malleo-incudal. 

2. The inco- orbicular. 

3. The orbiculo -stapedial. 

4. The stapedio-vestibular. 



(1.) The vialleo-incudal articulation. 

The convex surface on the lower and posterior part of the head o 
the malleus is received into the concavity on the anterior part offl 
the body of the incus ; when applied together, as they are retained 'I 
by their ligaments in a natural state, the surfaces of these two bones 1 
appear to be in close contact. Upon examining the articulating 1 
surfaces of the malleus and incus in a recent specimen, by means of I 
a lens magnifying five or six diameters, no appearance of cartilage \ 
can be detected ; and when touched with a fine probe, the surface 1 
is felt to be bard, as if no membrane were present. If, however, f 
these articulating surfaces be scraped with a small scalpel, fina i 
pieces of transparent membrane are removed. Examined by the 1 
microscope, this membrane, in some parts, is seen to be liomoge- j 
neous, having no appearance either of fibres or cells ; in other por- 
tions, delicate fibres can be detected, while here and there a single I 
layer of cartilage cells can be distinctly recognized. As a general j 
rule, more cartilage cells are to be found in the membrane remoTed j 
from the incus than in that from the malleus. 



' Mannal of finmEn Huliologf . B; Bnik and Hnile;. Tol. ii, p. 4M. 




THE CAVITY OP THE TTMPASUM. 



(2.) The inco'orbicular articulation. 

The orbicular bone is eometimeB described as a process of the 
incus. Careful examination of recent specimens shows, however, 
that the orbicular bone is connected to the incus by firm fibrous 
tissue. 

(3.) The orbiculo-atapediaLartumlation. 

The orbicular bone, on its surface towards the stapes, presents » 
slightly convex head, which is received into the superficial con- 
cavity on the head of the stapes. This convex surface of tlie orbi- 
cular hone is covered by a membrane, in which I have not been 
able to detect any cartilage cells. The outer extremity of the 
stapes is covered by a saucer-shaped cushion, soft to the touch ; 
and upon examination by the microscope, it is seen to be a disk of 
fibro-cartilage, bebig a representation in miniature of those existing 
between the bodies of the vertebrie, the circumference being com- 
posed of fibres arranged concentrically around cartilage cells which 
occupy the central position. 



I 



(4.) The stapedio-vestibular articulation 

is formed by the circumference of the base of the stapes, which is 
applied against the inner surface of the fenestra ovalis ; the stapes, 
as I have shown, being moved by mu.'scles to and fro in the fenestra 
ovalis, as a piston moves in a cylinder. I have not been able to 
detect any cartilage on the surface of either the base of the stapes 
or of the fenestra ovnlis, a very fine membrane alone being dis- 
cernible. 

The articulating surfaces forming the several articulations, arfll 
connected together by very delicate capsular ligaments. 

The next step of my inquiry was to ascertain by experiment how ' 
far these articulations tend to impede the passage of sonorous undu- 
lations through the chain of ossicles. As in the former experiments, 
these tympanic ossicles were represented by portions of wood ; while 
the cartilage and synovial membrane were represented by layers of 
vulcaniied india-rubber. 



818 THE DISEASES OF THE EAR. 

Experiment. — Three pieces of wood, each about five inches long 
and half an inch in thickness, were separated from each other by a 
piece of vulcanized india-rubber about as thick as ordinary writing- 
paper ; they were held together by means of elastic bands, and so as 
to assume the angular form possessed by the chain. The tuning- 
fork placed at the distal extremity of the chain, the other end being 
placed in the mouth, it was found that the sound was heard as dis- 
tinctly, and for the same length of time, as when it passed through 
the chain formed of the three portions glued together. 

Experiment, — A similar result took place when two layers of 
india-rubber were placed between each piece of wood. 

Experiment, — When eight layers of the india-rubber were pla<;ed 
between each piece of wood, there was still very little difference in 
the intensity of the sound when it passed through these, and when 
it passed through the portions glued together. 

Experiment, — One, two, or three fingers being placed between the 
first and second pieces of wood, and eight layers of india-rubber 
between the second and third, a very slight diminution in the in- 
tensity and duration of the sound was observed as compared with its 
passage through the pieces glued together, it being requisite that 
the fingers be pressed tolerably firm against the wood. 

Experiment, — If the back of the hand be placed against the teeth, 
and the end of the vibrating tuning-fork be pressed against the palm, 
the sound is heard very distinctly for several seconds ; and when it 
has ceased to be heard, if a piece of solid wood three inches long be 
substituted for the hand, faint vibrations are again heard, but for 
about four seconds only. 

Considering the extreme tenuity of the layers of cartilage and 
synovial membrane which arc interposed between the osaicula auditits, 
and the very slight influence in arresting the passage of the sonorous 
undulations produced by layers of india-rubber, the inference is that 
the articulations between the hones forming the chain in the human 
ear, impede very slightly, if at all, the j^dssage of vibrations from the 
membra na tympani to the labyrinth. 

The experiments and observations detailed above, lead to the fol- 
lowing conclusions : — 

First, — That the commonly-received opinion in favor of the sono- 
rous undulations passing to the labyrinth through the chain of 
ossicles in the human ear, is correct. 

Second, — That the stapes, when disconnected from the incus, can 



IX y OF THE TYMPAHDSl 



319 



conduct sonorous undulations from the tympanic cavity to the res- 
tibule. 

Third. — So far as our present experience extends, it appears that 
in the human ear sound always travels to the labyrinth through two 
media, viz., the air in the tjinpanic cavity to the cochlea, and one 
or more of the ossicles to the vestibule. 

After a detail of the above results, it will readily be assumed that 
a simple disconnection of the incus from the stapes is not productive 
of any large amount of dulncss of hearing. In the course of my 
dissections I have met with eight cases in which the incus was dis- 
connected from the stapes, and in no instance could 1 trace deafness 
specially to this cause. Some of the patients from whom the dis- 
sections were taken were undoubtedly deaf, but their dL-afness could 
be assigned to other causes than the existence of the solution of con- 
tinuity in the chain of bones. One of the patients in whom it 
occurred was not detected by the surgeon to he deaf; but this might 
arise from the fact that the lesion existed in one ear only. From 
some researches I have made on the subject, it appears probable 
that the cause of this peculiar lesion is hypertrophy of the mucous 
memhnine of the tympanum ; in cases of this disease, the supply of 
blood to the substance of the incus being interfered with. It is im- 
portant to rocognize the existence of this disease, and to do all that 
is possible to avert it by subduing any thickening of the tj-mpanic 
mucous membrane, but it remains for future investigations to decide 
to what extent this lesion interferes with the hearing power. 

Ca»e I. — A man, tet. 19 ; deaf in the left ear : died of apoplexy. 
In this ear the membrana tympani contained calcareous matter. 
The mucous membrane of the tympanum was very thick. The ex- 
tremity of both long and short process of the incus had disappeared, 
and the surface of the adjacent bone was rough. 

C«s*r II. — A man, let. 67. Right ear. — The inferior extremity 
of the long process of the incus has been absorbed, and the os or- 
biculare is attached to the stapes. On the inner surface of the 
head and long process of the incus are numerous orifices which 
lead into the interior of the bone, giving it a worm-eaten appear- 
ance. 

Case III. A boy, Kt. 5; died from scarlatina, and was not known 
to he deaf. Right car in a normal state. Left ear. — The os orbi- 
culare is separated from the incus, and ia attached to the stapes ; 
the stapes is fixed to the fenestra ovalis more firmly than natural. 



820 THE DISEASES OF THE EAB. 

The tympanic cavity contained mucus ; lymph was also effused, and 
bands of adhesion between the membrana tympani and the inner 
wall of the tympanum were in process of formation. The whole of 
the inner surface of the long process of the incus presented a worm- 
eaten appearance, and its lower extremity has disappeared, appa- 
rently from absorption. The os orbiculare is attached to the neck 
of the stapes, the part usually attached to the incus being free and 
rough, and projecting somewhat from the neck of the stapes. 

Ca9e IV. A boy, set. 8} years ; died from dysentery ; he was not 
ascertained to be deaf. Right ear. — The incus on the inner surface 
of its long process presented numerous foramina, and the orbicular 
process was partly absorbed, only a small rough portion of it re- 
maining attached to the incus — the inner surface of the extremity 
of the process being hollowed out, and having sharp margins. Left 
ear. — The incus is in the same state as that of the right ear, and 
the larger part of the orbicular process is attached to the stapes. 



CHAPTER XIV. 



THE MASTOID CELLS. 



As regards their functioDS, the mastoid cells may be' considered 
merely in the light of an appendage to the tympanic cavity ; but 
their peculiar conformation and intimate relations with the lateral 
sinus render a special study of their diseases necessary, previous to 
entering on which it is, however, important thoroughly to under- 
stand their anatomical relations. 

AruttomKal Obgervations, — Like the mastoid process, the mastoid 
cells vary much in size in different individuals. In some persons 
they occupy the whole of the interior of the bone behind the meatus 
extcrnua for the distance of an inch and a half; their vertical dia- 
meter is two inches, and they extend inwards as far as the fossa 
jugularis; in other cases the mastoid process is almost solid, and the 
cells communicating with it are small and few in number. The mas- 
toid cells may be considered as consisting of two portions : one con- 
tained in the mastoid process, where the cells have more or less of a 
vertical arrangement, the other situated between the mastoid process 
and the tympanic cavity : this latter portion is generally horizontal 
and frequently presents a concavity at its floor, in which mucus or 
other secretions are apt to lodge. On the inner surface of the mas- 
toid process is the sulcus lateralis, which is occupied by the lateral 
sinus. Xumerous orifices exist in this sulcus for the passage of 
veins from the mastoid cells to the lateral sinus, which is generally 



322 THE DISEABBS OF TUB EAR. 

the part first affected in disease of the mastoid cells occurring i 
the adult. These cells are hounded anteriorly hy part of the f 
rior wall of the meatua. At hirth and during early life, the ma 
process is in a rudimentary state, and the only representative of tli«l 
mastoid cells is the horizontal portion which is adjacent to the tym-.! 
panic cavity ; the extension of which backwards and downwards, iaf 
later periods, forms the cavity of the mastoid process. It i 
tial that the relations of this horizontal portion of the mastoid cellsl 
in the earlier periods of life should be well understood, since iliseaao'f 
occurring in it then produces entirely different results from those o 
a later period. If a vertical section be made so as to pass throu^ 
this horizontal portion in the temporal bone of a child about I 
years of age, these mastoid cells will be observed to be boandc 
externally by a part of the squamous bone, which is superior i 



I 




life Mutiiiil Prooeai U eipond. 

slightly posterior to the meatus externua ; and it is this pftrticolat 
part which becomes affected in cases of disease of the mastoid cella<l 
in early hfe. The upper wall of the horizontal portion of the n 
toid cells is formed by a layer of bone, continuous with that of thc'l 
upper wall of the tympanum. This lamina partakes of the disease I 
of the cavity, and thus the dura mater and cerebellum become liablal 
to be affected when, in early life, disease occurs in the mastoid oells* I 
Before the second year this cellular cavity is comparatively mutdtl 
larger than at a later period. 




THE MASTOID CELLS. 



The diseaaea of the mastoid cells in tlic child will be first described, 
ind afterwards those in the adult. 




d Ihroogh tU hnrii 


Dtg 


'P 


ortion 


oftb* 


rnnllj hj Ibo Isjer 


of 


bo 


c, whi 


b hu 


!Uiill; bccomea can 


"■" 


in 


""•■ 


Df dia- 



(d.) DISEASES OF TIIE MASTOID CELLS IN CHILDBOOD. 

The most frequent causes of disease in the mastoid cells, aa in 
the tympanum, at this period, are scarlet fever, measles, small-pox, 
and scrofulous affections. In the three former of these affections, 
the mucous membrane is usually the subject of chronic catarrh, 
becomes hyperirophied, and mucus collects in the cells. In the 
undeveloped state of the mastoid process in childhood, the mucus 
collects in the horizontal portion, bounded externally, as already de- 
scribed, by tbo Bf|uamous bono, and above by the continuation of the 
lamina forming the upper tympanic wall. Hence it is evident that 
the portions of bone liable to be affected by disease in the mastoid 
cells of the child, are the squamous bone immediately above and 
behind the external meatus, and the posterior part of the upper 
wall of the tympanum. Dissection shows also that these two parts 
are in fact those which do become affected, and that in cases of dis- 
ease attacking the mastoid cells in early life, the cerebrum w the 



324 



THE DISEASES OF THE EAE. J 



part of the brain which suffers, while, as we shall see in IsM 
periods of life, the cerebellum becomes affected. 

In disease of this part the discharge from the affected ear ofUai 
dates from birth, and is generally at first unaccompanied by any 
pain ; bo that too often (especially among working people) no notioai 
whatever is taken of it. In its earlier stages tbe discbarge appear^ 
to be purely sympathetic, and, as in many other cases of irritation 
of the tympanic mucous membrane, it proceeds from the meatus an4 
the outer surface of the membrana tympant. As the disease pn^ 
grosses, the tympanum becomes filled by mucus or scrofulous mattef] 
and the membrana tympani yields to the pressure on its inner sa 
face; and no doubt in some caaes, if a thorough outlet be thus mac 
for the discharge from the mastoid cells, while tbe Iiealth of tl: 
patient at the same time improves, no further mischief accrues ; bn) 
unfortunately the peculiar cooformation of this part of the mastoid 
cells usually prevents the free escape of the matter; part of it, i 
least, remains lodged in its concavity, or the whole is barred fr<iB 
exit by the closure of the tympanic cavity through the hypertroph] 
of the lining mucous membrane. In all fatal cases the discbaif 
has been deprived of a free egress. 

One of tbe peculiar features of the disease is, that it sometimflt 
causes death, by producing general cerebral irritation rather than 
inflammation. In tbe first two cases' which follow, there was i 
appearance of disease in the brain, pia mater, or arachnoid ; in t] 
third case these parts were but slightly affected in comparisoii with 
the large amount of disease in the ear. 

Case I, Scrofulous disease of the horizontal portion of the mcutoii 
cells before the first year of life; caries of the squamous bone; diaeatt 
of the dura mater. — J. R., aged thirteen months, was admitted nndep 
my care as an out-patient, at St. Mary's Hospital, on the 12tll 
February, 1852. Although &he bad a good color and was not thio^- 
her mother stated, that since her birth she had never been stronri 
and that she had been brought up by hand, on account of herse 
(the mother) having an abscess in one breast. The history n 
that at six years old a discharge was observed to flow from the right 
ear, which had continued to the present time with but short intflp 
missions. Three weeks ago an abscess formed at the back of tl 
ear and discharged into the meatus. On inspection, the surface i 

' \ iomcwhat uialogoiia eias htt besa aitcd u luTiag oacumd to Dr. Chamlnt. 




THE MASTOID CELLS. 



325 



the meatus was seen to be red, and ita gubstance so much tumefied 
as to prevent its being ascertaineil whether the raembrana tjmpani 
was or was not present. The discharge consisted of pua and mucua. 
The abscess behind the ear communicated with the meatus by an 
aperture at its posterior part. The ear was ordered to be syringed 
with warm water. 

February 19th. — Symptoms much the same, but the discharge 
more offensive. 

Until the Ist of April the symptoms gradually subsided, the dis- 
charge diminished, and the child appeared stronger. On the 2d, 
however, the discliarge grew more offensive, and leas in quantity, 
On the 8th the child cried, as if in pain, and started in her sleep. 

April 15th. — Leeches afforded some relief, and were ordered to 
be continued. 

19th. — Has bad shivering fits to-day. From this date the bead- 
symptoms gradually increased; the respiration became difficult, and 
the child died in convulsions on the 29tb. 

Atitopgy. — The part of the sterno-mastoid muscle attached to the 
mastoid process was discolored. The membranous meatus was much 
thickened, and of a dark purple color. The posterior part of the 
osseous meatus was carious; and the bone continuous with and above 
it, for a space the size of a sixpenny-piece, was also carious ; this 
being the portion of bone which bounds externally the horizontal 
mastoid space. The periosteum covering this carious bone is thick 
and soft- in some parts, and ulcerateil in others. There is also in- 
ternally a portion of necrosed bone about one-half the size of that 
externally ; and upon a section the inner surface is found to be part 
of the necrosed portion of bone which is seen externally, where it 
covers the tympanic cavity and extends above it. The outer surface 
of the dura mater which is in contact with the dead hone, is soft, 
spongy, and of a dark color, and partly filled the superficial cavity 
formed by the necrosed bone : in immediate contact with that bone, 
however, was a soft pulpy tissue. The membrana tympani was 
absent, the mucous membrane of the tympanum ulcerated, and the 
ossicles carious. The lungs were tuberculous, the mesenteric glands 
large, containing also scrofulous matter. 

The following case is very analogous to the one just reported. 

Case II, Scrofulous disease in the horizontal portion of the mas- 
toid cells in the first year of life ; caries of gquamous hone and dis- 
ease of dura mater. — E. B., aged aizteen months, subject to aero- 



■ TUE EAR. 



fuloue glands, was admitted under my care at the Si. George's » 
St. Jamea'a Dispensary, in November, 1849. When seen, 
was a large abscess behind tlie left car and discharge from f 





if boDS kbora the Mc 



mestUB. The membrana tympani was absent, tlio mucous i 
brane of the tympanum thick and red. At the bottom of g 
abscess behind the car, dead bone could be felt. Her mother state 
that there was discharge from the right car at the age of t 
months, which lasted six or seven weeks, and then disappears 
When five months old, discharge took place from the left ear, ai 
after continuing for a month, a swelling appeared at the back oFtl 
ear, which was opened and continued discharging, as well ns tl 
meatus, to the time I saw the patient. Soon after seeing her, tl 
symptoms of cerebral irritation, which had shown themselves : 
times in the form of great pain in the left side of the bead, rapid^ 
increased ; and in face of all the remedial measures employed, deat 
ensued in a few days. 

Autopgt/. — On slitting opon the abscess at the back of the eil 
the bone above and posterior to the meatus externus, over the spad 
of a sixpence, was denuded, and was rough, black, and soft: til 
external table had been removed. On making a vertical section C 
the bone through the horizontal portion of the colls, the walls a 
the latter were observed in a state of disease, and the cavity cOB 
tained purulent matter. The outer wall of this portion of the cell 



THE MASTOI 



327 



was csrioBB througliout. The membraiius meatus was softer than 
natural. The menibraua tj-mpani had been entirely removed by 
ulceration, as also parts of the tympanic mucous membrane; the 



A Verticil Secli 



external <r»ll, is 




small portions remaining being thick, soft, and of a livid color. The 
long process of the malleus had disappeared, and the remnant vub 
partially disconnected from the incus, as was the incua from the 
stapes. The inner surface of the carious bone is of a dark color, 
and is itself carious, presenting numerous small depressions. The 
thick, soft, and reil dura raater was separated from the carious bone 
by A transparent fluid. On examining the right ear, the same dis- 
ease appeared, but in an incipient state ; the meatus was soft and 
red ; the membrana tympani (luck, white, and concave; the mucous 
membrane lining the tympanum and mastoid cells, was thick and 
red; and there was a collection of mucus. Another case, which 
occurred under the care of Mr. II, J. Jolinson, when assistant-sur- 
geon to St. George's Ilospital, is as nearly as possible a counterpart 
of the one just cited ; and the specimen for which I am indebted to 
that gentleman, is almost a fac-simile of the preceding one. 

Disease sometimes extends upwards and outwards, and destroys 
nearly the whole of tlio squamous portion. A case of this kind was 
brought under my notice by Mr. Willing, of Hampatead. The fol- 
lowing are the particulars furnished by bim. 



328 THE DISEASES OF THE EAB. 

Ca%e III. Scrofulous disease in the horizontal portion of the mas- 
toid cells before the first year; destruction of a large part of the 
squamous hone by caries; disease of the dura mater; a small abscess 
in the cerebrum. — M. A. W., aged 11 months, the youngest of three 
children ; the other two were healthy. The parents are in bad 
circumstances ; the mother very emaciated, having during her preg- 
nancy had very insufficient food, owing to her husband, a brick- 
layer's laborer, being out of work for a long time. The child was 
first seen by Mr. Willing in June, 1850, and was then three months 
old, small and much atrophied. The mother said it was small when 
born ; and as she had no milk, she endeavored to bring it up by 
hand. There had been, she added, a discharge from the right ear 
since birth. On examination, a redness and tumefaction both of 
the meatus and ear were observed, with evident tenderness on pres- 
sure of the mastoid process, and the cervical glands were enlarged. 
The child suffered under diarrhoea, and was extremely weak. Cod- 
liver oil was administered, and emollients applied to the ear, which 
was syringed daily with warm water. Under this treatment, the 
child somewhat improved until October, when paralysis occurred on 
the left side of the face. The discharge grew more abundant, the 
soft parts round the ear became sloughy, and the mastoid process 
offered no resistance to pressure. These symptoms lasted till the 
death of the child in February. 

Autopsy^ thirty 'two hours after death, — The body was so much 
emaciated as to be scarcely larger than at birth. The dura mater 
was very thin, and the surface of the brain greatly congested, with 
patches of dark-colored blood scattered over its hemispheres, espe- 
cially on the right side, where, in one or two places, they extended 
to the depth of three or four lines into the substance of the brain. 
The cerebral veins were distended by coagula. At the surface of 
the posterior part of the middle lobe, on the right side, was a small 
abscess, the size of a pea. The ventricles contained about three 
ounces of thick, turbid serum. The middle cerebral arteries were 
distended by firm fibrin, and there were about four ounces of fluid 
at the base of the brain. The dura mater covering the petrous 
portion of the right temporal bone was separated from it by pus, 
and very much thickened. 

On examining the temporal bone, which Mr. Willing presented to 
me, I found that the part of the squamous portion between the root 
of the zygomatic process and the mastoid process had been entirely 



destroyed ; and that the larger part of the mastoid process had 
also disappeared, causing an aperture an inch in length, ftnd three- 
quarters of an inch in depth. The fietrous bone waa detached, and 
both its superior and posterior surfaces were carious. The small 
remaining portion of the mastoid cells contained scrofulous matter. 

In other cases the diseases may advance to a very considerable 
extent, aud then, supposing the health to improve, reparative efforta 
may be made. A highly interesting case of this kind was brought 
under my notice through the kindness of Mr. French, to whom I 
am indtbted for the opportunity of making a careful dissection of 
the ear. The case derives additional interest from the fact that it 
was the subject of judicial proceedings, the e,\citing cause of the 
fatal symptoms being a blow on the head. 

Gate iV. Catarrh of the mucoua membrane of the horizontal por- 
tion of the mastoid edle in childhood; caries of the bone; partial 
reparation by deposit of new bone. Death following a blow on the 
head; abeeesg in cerebrum. — E. C, aged 12, previoiisly in good 
health, was seen on the 3d of July, 1850, on account of violent pain 
in the head, chiefly in the left temporal region, accompanied by severe 
febrile symptoms. The day before she had received a violent blow 
on the head, during a scuffle ; she van thrown down, her head struck 
against the door, and subsequently against the wall : a, similar, but 
less severe assault, ivas repeated a few minutes afterwards. On 
examination, there was a fulness of outline, and a pufBness of the 
temporal muscle. The symptoms of cerebral irritation and fever 
rapidly increased ; n large abscess formed beneath the temporal 
muscle ; discharge issued from the car ; coma ensued ; and death 
occurred twenty-two days after the injury. It could not be ascer- 
tained whether there was a history of discharge from the ear in 
earlier childhood. 

Autopey. — The pericranium was found separated from the squa- 
mous bone by purulent matter ; the dura mater lining the squamous 
bone, and covering the upper wall of the tympanum, was thicker 
than natural, and but slightly adherent to the hone; the arachnoid 
and a portion of cerebral matter were attached to this part of the 
dura mater. In the cavity of the middle cerebral lobe was an 
abscess containing four ounces of pus. The petrous bone was dis- 
eased. The membranous meatus was thicker than natural, and its 
free surface was smooth, presenting no signs of ulceration. Tlie 
superior and posterior walls of the osseous meatus were roui 



330 THE DISEASES OF THE EAR. 

this roughness vas produced by a depoeJt of new bone, which 
also found to extpiid on llie outer surface of the sqiiaraoua bone, 
above the meatus, for a space measuring half an inch in its vertical, 
and an inch in its a ntero -posterior diameter. The posterior two- 
thirds of the membrana tympani were absent; the mucous membrane 
of the tympanum was healthy ; but in the passage to the mastoid 
cells there was a collection of pus and scrofulous matter, which bad 
not been freely discharged on account of the small size of the aper- 
ture leading into the tympanum, contracted as it was by the thick 
mucous membrane. The upper wall of the tympanum waa in a dis- 
eased state; the surface next to the dura mater being composed of 
a very fine scale of dead bone, about six inches long by four broad, 
which was perforated by small orifices, and eaten away posteriorly 
in parts. Beneath this dead bone was a layer of new bone, which 
formed the upper wall of the tympanum, and was continued upwards 
and outwards on the inner surface of the squamous bone to its upper 
margin. The old bone underneath and adjacent to the new bone 
was- worm-eaten, and had been the seat of the disease ; it was about', 
half an inch in breadth. 

There can be no doubt, from the examination of the 8pecitn«ii, 
that disease in the horizontal portion of the mastoid cells had com- 
menced in early childhood; that, as in the ciiaea previously cited, 
the aqnamouB bone became disciisod, the dura mater and the cere- 
brum being also affected, but not to such a degree as to cnduiger 
life. It would further appear, that as the bono was developed, new 
bone was deposited on each side of the diseased squamous hone, and 
extended into the meatus, which, it will he remembered, forms in the 
first few years of life part of the squamous bone ; and it is possible 
that, in spite of the disease of the brain and dura mater, the patieat 
might have lived many years, if no very active exciting cause had 
been brought into operation. At the same time, it is most probablA 
that the blow on the head would not have caused death bad thera 
not been pre-existing disease ; and in this view the Grand Jury 
contjurred. 

The peculiar anatomical relations of the mastoid cells in childhood' 
have now been pointed out : it has been shown, that in the first j«t' 
of life the mastoid process is not developed, and consists merely of. 
the horizontal portion, which is intimately connected with the 
bral cavity, to which, in childhood, disease is usually propagated' 
rather than to the cavity of the oerebellum. Those cases of disetso 




TOE MASTOID CELLS, 



331 



in early life which have been hitherto described, rouBt be, therefore, 
cooaidered as exceptions to the rule previously laid down by me, — 
tbat affections of the mastoid cells produce disease in the cerebellum. 



I 



(6.) DISEASES OF THE MASTOID CBLLS IN THE ADULT. 

Subsequent to the second or third year of life, when the mastoid 
process is somewhat developed, it will be found that the layer of 
bone bounding the horizontal portion externally, attains to a thick- 
ness of three or four lines, and becomes extremely dense. Hence, 
after the first or second year of life, disease is scarcely ever observed 
to extend from the horizontal portion to the outer surface of the 
squamous bone; but as the cells are developed posteriorly, and con- 
tract intimate relations with the lateral sinus and the cerebellum, it 
IB to these two parts that disease ia communicated. 

Cases of disease in the mastoid cells may be divided into acute 
and chronic. 

I. Acute infiammation of tlie mucous viemhrane lining the mastoid 
cells. — This affection is somewhat rare, and when it does occur, is 
usually subdued before it progresses to the bone or dura mater. 

Cases, however, are occasionally met with in which acute inflam- 
mation of the mucous membrane lining the mastoid cells ends in 
suppuration, the lateral sinus becomes inflamed, and abscesses occur 
in the brain. The following is a ease of the kind which occurred to 
Dr. Brinton, at the Royal Free Hospital, to whom I am indebted 
for the notes of the case, and for the opportunity of making the 
dissection. 

Case I. Acute inflammation of tjte mucous membrane lining the 
mastoid cells ; suppuration; disease of the lateral stmts ; abscess in 
the cerebellum. — A girl, aged 21, was admitted into the hospital, 
three weeks subsequent to an attack of scarlet fever. The history 
was, that since the fever, she has had a constant and abundant dis- 
charge from the left ear. On admission, this discharge was observed 
to be copious ; she was drowsy, and at times almost comatose, with 
a rapid feeble pulse, a cold body and limbs, and a hot face and head. 
In spite of all the remedies employed, the coma gradually grew more 
intense, and she died ten days after her admission. 

Autopsy. — An abscess was found in the left lobe of the cerebellum, 
of the size of a walnut. It extended to the surface, and thus came 



882 THE DISBASES OF THE EAR. 

in contact with a large quantity of pus, bounded by the diseased and 
distended walls of the lateral sinus, which latter contained pus and 
blood. There was an opening through the membrana tympani of a 
regular shape, and of a size one-third the whole diameter of the mem- 
brane. The upper wall of the tympanum was healthy, and not even 
discolored. The portion of the mastoid cells posterior to the incus 
contained some pus and blood mixed together ; this extended down 
as far as the mastoid process. The portion of the lateral sulcus, 
about an inch long by half an inch broad, which forms the exterior 
boundary of this part of the mastoid cells, was of a dark leaden 
color. The canals in this portion of the bone were also distended 
with black matter. 

It seems to me, there can be no doubt that, in this case, the puru- 
lent matter from the mastoid cells was the cause of the disease in the 
lateral sinus, for the bloodv/jssels between the two parts were dis- 
tended with dark pus and blood. 

II. Chronic inflammation of the mucouB membrane lining the mas- 
toid cells, — Cases of chronic disease of the mastoid cells usually take 
their origin before the adult period of life, although the more seri- 
ous symptoms may not be developed until after that period. As 
in disease of the tympanum, the cases now under consideration 
commonly originate in chronic inflammation of the mucous mem- 
brane. Whatever may be the cause of this inflammation, — whether 
scarlet fever, measles, or an ordinary cold, — the result is the secre- 
tion of a larger quantity of mucus than is natural, which in the 
milder forms of the affection is afterwards absorbed, or else dis- 
charged through the tympanic cavity and Eustachian tube, into the 
cavity of the fauces ; but in the more severe, to which attention has 
now to be directed, the mucous secretion is too abundant to escape 
from the cells, and the bone becomes affected. 

The effects of chronic disease in the mastoid cells upon the lateral 
sinus and cerebellum are : — 

1st. Suppuration in the lateral sinus with or without secondary 
purulent deposits. 

2d. Inflammation of the dura mater and arachnoid, and the forma- 
tion of pus on the surface of the cerebellum. 

3d. Abscess in the cerebellum. 

The history of cases of chronic disease in the mastoid cells bears 
some analogy to that of those occurring in the tympanic cavity, al- 
though, as a general rule, there is more irritation from the outset of 



333 



the affection, and consequently atteotton is attracted to the case in 
its early stages ; and this is the reason, as will be seen when the 
treatment is spoken of, why the disease is more umenahle to reme- 
dial measures than when it attacks the tympannm. The following 
may be taken as the ordinary history of a case of disease advancing 
from the mastoid process to the lateral sinus or cerebellum. The 
patient, who has often a tendency to glandular enlargements, has 
suffered when a child from pain in the ear, followed by discharge. 
During childhood, and perhaps up to adult age, there have occurred 
attacks of pain and discharge at intervals of some months. Between 
the attacks there is often a sensation of pain in the region of the 
mastoid process and back of the head, and giddiness sometimes 
comes on. These syniptoms are aggravated by fatigue or any other 
depressing influence. Upon examination, the surface of the meatus 
is seen to be red, and to be the source of the discharge. No perfo- 
ration exists in the membrana tjmpani, which, however, is white and 
thickened, so that the discharge is purely sympathetic. The surgeon 
is more commonly called, however, to cases where the symptoms 
have become much more urgent, and where, indeed, the disease htis 
advanced so far that the brain or its membranes have become so 
greatly disorganized as to defy all remedial measures. 

Cases of disease in the mastoid cells terminate fatally from two 
different causes. 

1st. From purulent infection, arising from the introduction of pus 
into the circulation through the lateral sinus, 

2d. From disease of the cerebellum or its membranes. 

Caaea of purulent ivfeciion have not been met with when the 
disease occurs in the tympanic cavity. On account of the proximity 
of the jugular vein to the lower wall of the tympanum, it is, however, 
quite possible for disease to extend to the venous system. 

Dr. Abercromhie published an interesting case of purulent infec- 
tion from disease of the ear ; but the subject has been more 
thoroughly investigated by Dr. Watson, who, although deprived of 
the opportunity of making po»t-morUm inspections of the highly 
important cases he has so fully described, had no doubt in his mind, 
and leaves no doubt in the minds of his readers, that the cause of 
death was the introduction of pus into the system from the mastoid 
cells. Dr. Bruce haa since published some valuable cases bearing 
upon the subject ; Mr. Wilde gives the details of a case in his work 
on the ear ; and more recently still, Dr. Gull, in the Guy's Hospital 



331 



TUB DISEA 



OF THE EAR. 



Reports, has tlirown much light on the subject. The facts brongbt 
forward by these gentlemen, coupled with those which are now to be 
related as the result of my own experience, will, I trust, lead to A 
thorough comprehension of the nature and progress of the dieeaae. 
Dr. Abercrombie's case is the following; — 

Diiease of the maetutd celU ; deposit in the lateral mins ; Mcon- 
dary deposit in the pleura. — A young lady, aged 15, had been liable 
for six or seven years to attacks of pain in the right ear, followed 
by discharge of matter ; but she had been free from any of these 
attacks for some time previous to the abscess which forms the sub- 
ject of the following history. On the 25lh April, 1822, she com- 
plained of cold shivering through the day, and in the evening bad 
headache with pain iu the right ear, symptoms which continued on 
the following day. On the 28th she was seen by Mr, Brown, who 
found her with quick pulse and foul tongue, severe pain in the ear, 
and slight headache. On the 20th some discharge took place from 
the ear, but without relieving the pain which continued with violence 
until the next day. On the 1st of May the pain had somewhat 
abated in the ear, but had extended over the right side of the head ; 
pulse frequent. General and local bloodletting were employed 
with partial relief. I saw her on the 3d ; the headache was then 
rather abated ; the pulse was frequent and weak ; she had a pale, 
unhealthy aspect, and a look of oppression hordoriug upon coma. 
The pain was chiefly referred to the parts above and behind the 
right ear, where the integuments were painful on pressure, and, at 
one spot near the mastoid process, felt soft and elevated. A pnnc- 
ture was made at this place with a lancet, but nothing was discharged. 
Topical bleeding, blistcriug, &c., were recommended. 

4th. — Pulse in the morning 148 : in the course of the day it fell 
to 84 ; looking very languid and exhausted. 

5th. — Dark-colored matter of inlolerable fetor began to be dis- 
charged from the puncture which had been made heliind the ear. 
The opening here was enlarged, and a probe being introduced, the 
bone was felt bare and rough over a considerable space; headache 
much relieved ; pulse natural. 

6tb. — Great discharge from the opening, headache much relievedi 
pulse 112 ; complained of some pain in the left side of thorax, and 
there was considerable diarrhoea, 

7lh. — No headache; there was much discharge of fetid matter 
from the opening near the mastoid process, and a probe introduced 




THE MABT0:i> 



335 



b^ it pasHed downwards and backwards, undor the id teguments, ae 
far aa tbe spine. 

8tli. — Pain in the thorax continued, and was now bo urgent that a. 
smalt bleeding was employed with partial relief; it could not be 
carried further on account of increasing weakness; pulse 140, 

9th, — Said she felt better, and made no complaint of pain ; pulse 
very rapid, and strength sinking. 

Died on the lOtb. 

Autopsy. — Every part of the brain was in the most healthy state, 
except a small portion on the right aide, near the ear, which was of 
a dark leaden color ; the tinge, however, was entirely superficial. 
The right temporal bone externally was hare, through a great part 
of its extent; internally, it was in many places rough and dark- 
colored ; and there was some dark-colored matter betwixt it and the 
dura mater. The dura mater at this place was, for a considerable 
space, thickened, spongy, and irregular ; the coats of the right lateral 
sinus were greatly thickened through its whole extent, and the 
capacity of the sinus was very much diminished by a deposition 
similar to that which occurs in the cavity of an aneurism. The in- 
ternal ear contained dark-colored matter; the left cavity of the 
pleura contained fully a pound of puriform fluid ; the left lung was 
collapsed, dense, dark colored, and covered by a coating of eoagu- 
lable lymph. 

From the examination made by me of deposits in the cavity of 
the lateral sinus, I have no doubt that the matter alluded to in the 
above case, consisted of coagulated blood mixed with pus. 

The following is one of Dr. Watson's cases : "A hoy, 11 years 
old, had had a discharge of offensive, purulent matter from bis ear 
«nce the time when, four years before, he had gone through an at- 
tack of scarlet fever. In August, 1833, he went for a walk into 
Kensington Gardens, and there lay down and slept upon the damp 
grass. The next day he was attacked with headache, shivering, and 
fever; strong rigors, followed by heat and perspiration, occurred 
very regularly for two or three days in succession, suggesting the 
suspicion that his complaint might be ague ; but then pain and swel- 
ling of some of the joints came on, and were at first considered 
rheumatic. However, the true and alarming nature of the com- 
plaint soon became apparent; abscesses formed in and about the 
affected joints, and one of these fluctuating swellings was opened, 
ftnd a considerable quantity of foul, grumous, dark-colored matter 



886 THE DISEASES OF THE EAB. 

let out. After about a fortnight, the child sank under the con- 
tinued irritation of the disease. The hip-joint presented a frightful 
specimen of disorganization ; it ^as full of unhealthy sanious pus ; 
the ligamentum teres was destroyed, the articular cartilages were 
gone ; and matter had burrowed extensively among the surround- 
ing muscles. The knee and ankle-joints of the same limb were in a 
similar condition. Unfortunately the head was not examined, but 
that the fatal disorder had penetrated from the ear to the dura 
mater, I entertain no doubt ; in all probability the inflammation had 
involved the veins or sinuses of the head.'* 

Having given another case of a similar nature, Dr. Watson 
says : — 

^^ I much lament that, in these instances, the direct link of con- 
nection between the disease of the ear and the disorganization of 
the joints was not demonstrated, for seeing (they say) is believing. 
Yet the pain of the ear, the discharge of pus from the external 
meatus, the subsequent pain in the head, coming on with fever and 
rigors, and followed, after a short interval, by destructive suppura- 
tion in several distant parts, and, in the latter case, the actual 
femoral phlebitis, — these circumstances form a chain of presumptive 
evidence amounting, in my judgment, to moral certainty, that the 
fatal mischief, in each case, found entrance through the porches of 
the ear, and that the dura mater underwent inflammation. The 
same evidence is scarcely less aflfirmative of the complication of 
cerebral phlebitis. Perhaps the veins of the diploe, which, in the 
cranial bones, are of considerable magnitude, were involved in the 
inflammatory mischief; perhaps the large sinuses of the brain. The 
close proximity of the lateral sinus to the diseased bone, and its 
formation by a duplicature of the dura mater, would seem to render 
such a complication highly probable." 

The direct link of connection between the disease 'in the ear and 
that of the circulating system was pointed out by Dr. Bruce, and 
also in the case cited by Mr. Wilde. In the latter, " The membra- 
nous walls of the right lateral sinus, throughout the whole of the 
mastoid portion of its course, were much thickened, and their lining 
presented a sloughy appearance, being covered with lymph of a 
greenish hue, and smeared with unhealthy purulent matter. This 
condition of the lining membrane extended along the jugular vein 
and superior vena cava to within a short distance of the entrance of 
the latter into the auricle. The left cavity of the pleura contained 



THE MASTOID CELLS, 



337 



abotit four otmces of a thin fetid matter." In addition to the facts 
above cited, all that is required ia, an account of the exact condi- 
tion of the ear ; and this has been supplied by me in the following 
case, which occurred to Dr. Ilealc, at the Free Hospital. 

Caee II. Pv» in mastoid cells ; caries of the lateral sulcus ; put 
in the lateral sinus; secondary deposits. — Harriet G., aged 20, was 
admitted into the hospital on the 9th March, 1850. She had great 
fluttering and irregular vibrating action of the heart, resembling 
erytblsmus mercurialia, but which subsided in a day or two. She 
waa deaf in the left car, and had long been subject to intense ear- 
ache, with occasional fetid discharge from the meatus. She was 
restless, sleepless, occasionally delirious, and had no appetite. Soon 
after her admission, an abscess formed just above the left collar-bone, 
which discharged large quantities of matter until her decease. The 
disturbance of the heart's action returned after three doses of hyd. 
c. cretfi, six grains having been given every six hours ; but it again 
subsided in about two days. She then had severe delirium, which 
abated after a sudden large and fetid discbarge from the left ear : 
finally she had erysipelas, violent delirium, succeeded by coma, and 
died on the 15th of April. 

Autopsy, — A very large excavated abscess, with sinuses in vari- 
ous directions, was exposed at the root of the nock on the left side, 
communicating with and extending through the whole of the carotid 
sheath. The internal jugular vein was full of matter, which was 
also found burrowing down in the direction of the vena innominata; 
a fibrinous clot was found in that vein extending into the descending 
rena cava; and having been examined by the microscope, was found 
to contain pus globules. The lungs were filled with a frothy and 
purulent infiltration, without consolidation, and there was a small 
circumscribed abscess between the pleura pulmonalis and the right 
lung, which, ho*ever, did not extend into the substance of the latter. 
The heart was healthy ; the liver pale-colored. The cerebrum was 
healthy ; the arachnoid membrane, in parts, appeared smeared over 
with pus, more particularly in the posterior part, near the falx, 
joining the tentorium. The tentorium covering the left lobe of the 
cerebellum was much inflamed, thickened, and had matter between 
it and the arachnoid covering that lobe of the cerebellum ; and im- 
mediately beneath this, on cutting into the cerebellum, a circum- 
scribed abscess, about the size of a walnut, was discovered. This 
was nearer to the falx cerebelli than to the outer margin of the 
22 



838 THE DISEASES OF TFIE EAR. 

cerobelluin : the part of the cerebellum In contact with the cranii 
bonea was healthy. 

The petrous bone was examined by myeelf, and reported upon a> 
follows : — 

The meatus extcmus contained purulent matter. The glandola) 
and periosteal portions of the membranous meatus were much soti 
than natural, and adhered but slightly to the surface of the bona 
The bone forming the upper and outer half of the tube was found 
to present numerous foramina for the transmission of bloodvessel^ 
which were much larger than natural, and some of them surrounded 
by delicate layers of new bone : through the larger of these forai 
mina, good-sized bristles could be passed, and they appeared to c 
muaicate with canals in the interior of the bone, which were then** 
selves continuous with orifices in the sulcus lateralis at its i 
surface. The lateral sinus was of a dark brown color, and the dun 
mater forming its exterior wall was entire. The sinus was full « 
coagulated blood, mixed with purulent matter. The dura mata 
constituting its anterior wall, and which was in contact with 1 
surface of the bone forming the sulcus lateralis, was very thick a 
soft ; portions of it were destroyed by ulceration, and the bone w«| 
exposed. This bone was dark in color, and covered by masses of 
lymph and pus; its surface was rough, presenting throughout iiamo> 
rous orifices and tortuous grooves, — -an appearance which was pro 
duccd by the nearly complete absence of the internal table of 1 
skull, that (with the exception of tvio scales, each measuring sbool 
two lines in diameter) having been destroyed by caries. 

A carious orifice existed between the cavity of the cerebelliua 
and the mastoid cells. The bone forming the jugular fossa waa a 
carious. There was an orifice in the posterior part of the membrani 
tympani. 

Tho tympanic mucous membrane was much thicker than naturaly 
and in the upper osseous wall were observed a few small foramini 
for bloodvessels, and a carious orifice of a size sufficient to allow tl 
passage of a small pin. 

The mastoid cells at their upper part formed a cavity about thu 
size of an ordinary horse-bean, and contained pus. This cavi^ 
communicated posteriorly with tho lateral sulcus by means of a 
(Jrifice throe lines in diameter. Anteriorly, the orifice into tl 
tympanic cavity was not more than two lines in diameter, and «i 
placed above the level of the floor of the cavity containing the pna.r 




TUE MASTOID CELLS. 



It lias been already stated that the anterior wall of the mastoid 
cells is formed by the posterior wall of the osseous external meatus. 
The latter wall, in some cases, becomes carious, and matter is dis- 
charged through it, as was the case in the following interesting in- 
stance, but the orifice was not large enough to be effectual in reliev- 
ing the symptoms. 

Cate III. Pu» and scrofulous matter in the mastoid cells ; commU' 
nication with the lateral sinus hi/ the reins; secondary deposit in pleura. 
— Kitty Di, aged 15, was admitted under my care as an out-patient 
of St. Mary's Ilospitnl on the 16th of February, 1854. She stated 
that six months pre^nously she suffered from pain in the left ear, 
which was followed by duluess of hearing in it, as well as in the 
right ear, which had remained to the present time, aceompanicd by 
a discharge from the left ear. On examining the left ear, a small 
red polypus was seen at the inferior part of the meatus, near to the 
membrana tympani : the latter membrane Was white. She did not 
complain of pain in the head. Gentle counter-irritation was or- 
dered behind the ear, which was to be syringed with a weak astrin- 
gent lotion. The patient continued much the same until March 
27th, when she was admitted, in my absence, as an urgent case, 
under Dr. Sibson, into the hospital. When admitted, she was par- 
tially unconscious, extremely prostrate, and could not speak ; the 
skin was parched ; the tongue brown and dry ; pulse 140, very small 
and thready : pupils sluggi.sh — the left rather more contracted than 
the right. On inquiry, it was found that, three days before, a marked 
difference was perceived in her manner, and attributed to the pain 
in the head and loft ear, of which she complained greatly. She was 
unable to do any work. On the 25th, she kept her bed ; on the 26th, 
she became still worse ; and on the 27th, application was made at 
the hospital. Upon being seen by one of the officers, she was at 
once a<imitted. Stimulants were freely administered, and the pa- 
tient somewhat rnlltcd : during the night, she was very restless, and 
wandered a good deal. 

28th. — Seems quite sensible of all that is done to her, but does 
not speak, muttering only to herself. Pulse 140; skin hot, though 
some moisture is still apparent. Loud sonorous rhonchus of right 
lung ; the head is held to the right t^ido, the mouth also is drawn to 
the right; the nostrils are expanded ; and there is partial paralysis 
of some of the muscles on the left side of the face. She was sup- 
ported by stimulants at the same time that a leech was applied to 



340 THE DISEASES OF THE EAR. 

the neck. 10 p. M. — ^Very low, surface cold ; skin clammy ; face 
livid ; subsultus tendinum ; pulse feeble and irregular. 

29th. — Much as yesterday ; rambled during the night ; voids urine 
involuntarily ; tongue brown and moist ; pulse 140, very small. 
During the evening very low ; voided urine in the bed ; muscles 
suddenly contracting. 

30th. — Slept badly; at times wandered much; breathing hurried; 
pulse 140 ; nostrils dilated. She gradually became worse, and died 
at 2-15 P.M. 

Autopsy. — Cerebrum firm ; ventricles dry ; gray substance very 
dark. Over the left lobe of the cerebellum, at the posterior part of 
the petrous bone, is a dark bluish portion, of the size of half-a-crown. 
The gray matter of the cerebellum very blue to the depth of one- 
eighth of an inch, and beneath the discolored spot the substance of 
the cerebellum was slightly softened. There were considerable ad- 
hesions between the lu#g8 and the pleura costalis ; and also tuber- 
cular deposit covered by an unhealthy plastic, fibrinous exudation ; 
the pleural cavities contained a pint of fluid. The dura mater form- 
ing the posterior wall of the lateral sinus (where it is situated in the 
temporal bone) was of a dark color and soft ; the sinus contained, at 
its upper part, a firm coagulum of dark-colored fibrin ; at its lower 
part it was full of dark-colored pus. The anterior wall of the sinus 
was attached to the bone much less firmly than natural. The mas- 
toid cells were full of pus and scrofulous matter ; and their anterior 
wall presented an orifice, about two lines in diameter, which opened 
into the meatus externus. The incus and the thick mucous mem- 
brane around it prevented the pus from escaping. The orifices for 
the passage of the bloodvessels from the mastoid cells to the lateral 
sinus were somewhat larger than natural. 

It will be observed that m this case there was no caries of the bone 
towards the cerebellum ; and the only means by which the disease 
from the mastoid cells could be propagated to the cavity of the late- 
ral sinus must have been the veins. 

A sufficient number of facts have now been cited to show how very 
insidiously disease progresses from the mastoid cells to the cerebellum 
and lateral sinus, and to prove that the sinus may become influenced, 
purulent matter developed within it, and secondary abscesses pro- 
duced, without the occurrence of caries in the bone forming the sinus 
lateralis. 
' It has been already stated that the cause of disease advancing 



THE MA8T0I 



341 



from the mastoid cells to the latera.1 sinus and the brain, is the 
retention of the discharge within these cells, instead of its finding a 
free egress through the external meatus. 

In the cases of death from purulent infection which have been 
detailed, it will have been observed that there was merely a small 
aperture in the membrana tympani, ao that only part of the matter 
could be discharged from the mastoid cells ; and it seems to me 
probable, that if, in any way, a sufficient portion of the membrana 
tympani had been removed at the beginning of the attack, to permit 
of a thorough evacuation of the contents of the mastoid cells, the 
bone would have remained free from disease — an opinion which 
seems corroborated by the following case : for it will be noted that 
the scarlet fever appears to have attacked the mastoid cells of each 
ear e((ually. In each, the lower half of the membrana tj-mpani was 
destroyed; but in the organ of which the bone became diseased, it will 
be remarked that the lower margin of the remnant of the membrana 
tympani fell inwards towards the promontory, to which it became 
attached, and by this means the escape of matter from the mastoid 
celts was prevented ; while, in the other ear, the lower margin of 
the membrane remained free, and the discharge readily escaped. 
The case, of which the particulars were sent to me by a friend, 
together with the petrous bones, is of importance on other grounds, 
since it shows the coexistence of disease in the mastoidal and tym- 
panic cavities, and the contemporaneous production of disease in the 
cerebrum and cerebellum. It is further of interest as pointing out 
how very little relation exists between the condition of the bono 
forming tbo lateral sulcus, and the contents of the lateral sinus. 
In some cases already described, the lateral sinus contained a large 
quantity of pus, but the hone was not carious ; whereas in the fol- 
lowing case, where the hone forming the lateral sulcus was so much 
diseased that a large portion was necrosed and completely detached 
from the surrounding parts, there was no pus in the sinus. The 
explanation of this circumstance, found also in other cases, is most 
probably to be sought for in the fact, that when there is extensive 
caries of the substance of the bone, there is more space for the 
matter, and hence the pressure upon the sinus is comparatively 
slight. 

Cage rV. Catarrhal infiammation of the mueoug membrane lining 
the mastoid eelh of the ear; retention of the discharge in the right 
ear hy the adhetion of the membrana tympani to the promontorif; 



842 



caries of the right lateral sulcus, aiid abscesses in the eerefTum 
cerebellum. — J. R., aged 12, hail an attack of scarlet fever two years 
previously, since ivliicli he bas hud a discharge of matter from eaoi 
ear, and a considerable diminution of the hearing power. On th« 
l-3th of February, 1854, he complained of rigors and general 
malaise; these were followed by febrile symptoms and pain behind. 
the left ear. On the 15th, a small abscess was observed behind 
ear, which, when opened, discharged a sanguineous fluid. Tbert 
was a slight degree of stupor, and the discharge continued withont 
relief to the pain. On the 20th, he had somewhat improved ; paiq 
less ; stupor diminished ; discharge from the meatus as well as from 
the abscess. On the 21st, another abscess formed over tbo mastoid 
process ; pulse small and frequent, discharge very fetid. 22d.— • 
Decidedly improved in every respect ; but the pain and feverish 
symptoms returned on the 23d, in an aggravated form ; the drowa- 
ness much increased, so that he had to be roused up to take his 
food, and he soon fell back again into the same state. He grada> 
ally became weaker; the urine and fjeces were passed involuntarily: 
the stupor was increased ; and the prostration was extreme, Oo 
the 4th of March, he had two severe rigors, and constantly cried out 
on account of the severe pain in the head. The pain gradually 
creased till the 6lh of March, when attacks of pain came on every 
ten minutes, and of so acute a character as to cause him to scream.. 
During the succeeding seven days, he suffered much less pain ; 
there was a copious sanious discharge from the car and from th^ 
abscess. On the loth, the stomach became irritable, and rejected 
everything introduced into it. The pain, at times, was extreme.. 
On the 16th, at twenty minutes past twelve, he suddenly becams 
convulsed, the face and chest were of a deep blue, the pulse 
imperceptible at the wrist, the pupils dilated and fixed, aud in thit 
state he died. Upon inquiry, it appeared that, smce the fever, tb« 
patient had suffered from frec[ueat headaches, languor, and drowa^ 
ness. 

Autopsy. — The bloodvessels of the dura mater were highly 
gested. In the sulcus lateralis was a portion of necrosed bone, 
about three-quarters of an inch long, and half an inch broad, and 
qiiite detached from the surrounding bone ; its outer part formed & 
portion of the mastoid process ; between this detached piece of bone: 
and the dura mater was a large quantity of purulent matter, whi^i 
communicated with tlie superficial abscess behind the ear. An aV 



THE MASTOID CELLS. 



seess was also found in the substance of the middle lobe of the cere- 
brum. Upon examining tbe car, the lower half of the membrana 
tympani was found to have been destroyed, and the inferior half of 
the upper part was attached to tbe promontory, bo that the upper 
portion of the cavity of tbe tympanum was closed, and the matter 
Beereted there had no exit. The tympanic mucous membrane was 
thick, and ulcerated in parts, and the mastoid cells presented a 
large cavity full of pus. In the opposite ear tbe lower two-thirds 
of tbe membrana tympani were absent, but the upper part was not 
adherent to the promontory; so that there was ample room for the 
egress of discbarge from the tympanum. The tympanic mucous 
membrane was thick, but not otherwise diseased; the bone was 
healthy. 

A case very similar to the last cited was brought under my notice 
by Dr. Ogle, who was so good as to give me the preparation. In 
this case the disease had made way externally, so that the mastoid 
process was broken up, while the sulcus lateralis was by comparison 
but slightly affected. The veins seem to have been tbe medium of 
communication with the lateral sinus, and the cause of the deposit 
of pus within it. The question would probably be asked, why, in 
these cases of disease in tbe mastoid cells, does not the matter make 
its way outwards through the external wall of tbe mastoid process? 
It will be observed, that this outward advance of tbe disease baa 
already been noticed in three of the cases ; but while this was going 
on, the internal wall of tbe mastoid cells, or of the lateral sinus, 
became so diseased as to destroy life. It must also be borno in 
mind that cases are of very frequent occurrence where the disease 
advances esternally, destroying part of the mastoid process, which 
often comes away en inatse, and where the brain and its membranes 
suffer bat slightly. Cases of this kind generally originate in an at- 
tack of scarlet fever, or of cold ; sometimes the symptoms of cere- 
bral irritation are but slight, at others, very severe, and usually sub- 
side when there is a free discbarge externally, as will be seen when 
speaking of the treatment. 

In the course of the previous observations, it has been stated that 
in cases of disease within the tympanic cavity catarrh of the dermoid 
meatus takes place, as the result of sympathetic action, and without 
the existence of any orifice in the membrana tympani. It is impor- 
tant to bear this fact in mind, because the attention of the surgeon 
is apt to be drawn from the real disease towards the affection of tbe 



S44 THE DISEASES OF THE SAB. 

meatus ; indeed, in many cases of irritation of the external meatus, 
arising from obstruction of the Eustachian tube, the primary disease 
is often overlooked, and the cause of deafness supposed to reside in 
the irritation of the meatus. The meatus externus not only sympa- 
thizes with the condition of the tympanic cavity, by becoming the 
seat of catarrh, but not unfrequently polypi are developed within it. 
When this happens in cases where there are symptoms of disease of 
the bone, great care must be taken not to increase the irritation of 
the ear by interfering with the polypus. The following case is, in 
this view, worthy of the most attentive consideration. It was laid 
before the Pathological Society in 1851, by the late Mr. Avery, and 
reported upon by myself. 

Ca^e V. Carie% of the mastoid cells ; polypi in the external meor 
tti4t ; abscess in the cerebellum, — A man, aged 35, had suffered for 
some years from frequent earache of a severe character, accompa- 
nied by discharge. About five weeks before his death a large 
polypus was removed from the external meatus. This was followed 
soon after by great pain at the back of the head, in the right side, 
and down the neck and shoulder, of a plunging intermitting cha- 
racter. 

These pains were treated at first as neuralgic ; but they increased 
in severity and frequency, and rest could only be obtained by the 
oft-repeated doses of laudanum. The patient appeared generally to 
be dull, heavy, stupid, and incapable of making any exertion. He 
several times remarked that people must have thought him intoxi- 
cated when in the street, as liis gait was so very unsteady that he 
was often obliged to lay liold of the rails to prevent himself from 
falling. He ultimately became comatose and died. 

Autopsy, — The brain was found to fill the cranial cavity, and the 
convolutions were very closely pressed together. The arachnoid 
membrane was extraordinarily dry ; the lateral ventricles containe<l 
a very large quantity of clear limpid fluid, and the fornix and 
septum lucidum were very white and soft. On separating the cere- 
bellum from the petrous portion of the temporal bone, a gush of 
thick creamy pus took place, and an abscess was found occupying a 
cavity in the right lobe, largo enough to hold a pigeon's egg. The 
contents of this cavity were very fetid, and the walls were firm and 
lined by false membrane, being thin at the point where the cere- 
bellum rested on the aquoeductus vestibuli of the temporal bone. 
At this spot there was a small ulcerated opening in the dura mater. 



HE MASTOID CELLS. 



S45 



eommoni eating with a carious portion of temporal bone, and it was 
here that the disease had been continued to the cerebellum. There 
■was no loose lymph in the cavity of the araebnoid, and only a thin 
film covering itnen.r the ulcerated opening in the dura mater. The 
unsteadiness of his gait, in connection with ihe abscess in the cere- 
bellum, was very remarkable; but it could not be ascertained, on 
repeated inquiry, that the want of power over the regulations of his 
movements affected one side of tlio boiiy more than the other. 

Upon examining the petrous bone, two small polypi were found 
attached to the npper and posterior part of the memhrana tympani, 
which was very thick, and presented a small orifice at its anterior 
part. The membranous meatus was easily detached from the bone, 
which was darker and rougher than natural. The mastoid cells 
were carious and full of pus. On rennoving the dura mater from the 
posterior surface of the petrous bone, the upper part of the sulcus 
lateralis was found to be carious for a space three lines in diameter, 
and the orifices in the hone were filled with fibrin. The dura mater 
covering the sulcus lateralis was softened, but the disease had not 
penetrated to the cavity of the sinus. The dura mater adjacent to 
the fossa jugularis was soft and partially destroyed by ulceration. 
The bone beneath it was carious, and was found to form part of the 
posterior wall of the inner extremity of the mastoid cells, from which 
the disease bad been propagated. 

In addition to the other points of interest in this case, is the fact 
that diwease may be propagated to the jugular vein from the mastoid 
cells, without the intervention of the lateral sinus. 

I believe it to be rare for disease in the mastoid cells to manifest 
itself for the first time after the adult period. The following is an 
instance of the kind. It is impossible to say how long there had 
been incipient disease ; but from the appearances after death, it is 
probable that it was of long standing. The case is of great interest, 
from the fact of the existence of so large an amount of disease, and 
the presence of formidable symptoms for so short a time only before 
death. 

Co«e VI. Caries of the mastoid cells; destruction of the sulcus 
lateralis; pus discTiarged behind thj- ear. — T. D., aged 29, was under 
the care of a friend, in May, 1851, on account of diabetes. He 
remained under treatment for ten weeks, during which time he did 
not complain of pain either in the head or ear. At the expiration 
of the ten weeks he went into the country for a fortnight, and shortly 



THE DISEASES DP THE GAR. 

after Kis return he began to speak of pain in the head, wfaidi iru 
principnlly referred to the riglit mastoid process. This pain, accom- 
panied by violent earache, gradiialij increased, and was attended 
by a purulent discbarge from the ear. Drowsiness, giddiness, and 
stupor supervened. These symptoms were not relieved by the most 
active treatment. Six weeks previous to his death, an abscess was 
opened behind the right ear, from which a large quantity of pus waa 
discharged. No relief followed, the head-symptoms gradually in- 
creasing until his death. 

Autopsy. — The external meatus contained a large quantity of 
muco-purulent discharge ; the surface of its dermoid layer was 
denuded of epidermis, and its substance much tumefied. The mem- 
brana tymponi was entire, but of a dull leaden hue, and much softer 
than natural. The cavity of the tympanum contained a great quan- 
tity of purulent matter, and its lining membrane was vascular, thick, 
and flocciilent. The incus had disappeared; the stapes was in titUy | 
but was surrounded by bunds of adhesion. The osseous walla of tha J 




conHitlna of Lhe Sulcus Lnteralin. 



tympanum were healthy. The mastoid cells were full of purulent 
matter, and the bony laminie dividing the cells were extensively 
carious, large portions of them having been destroyed. The wliole 
of the posterior wall of these cells, usually forming the sulcus late- 
ralis, was completely destroyed, and in its place was an orifice tuea- 



34T 



enring an inch and a quarter from above downwards, and more than 
half an inch in breadth. The orifice in reality corresponded exactly 
■with the sulcus lateralis, as situated in the temporal bone, iviih the 
exception of half an inch before it reaches the fossa jugularis. A 
circular orifice, about the size of a pea, existed at the posterior part 
of the mastoid process, which communicated with the aperture just 
mentioned, on the one hand, and with the abscess behind the ear, on 
the other. The membranous lateral sinus was much attenuated, and 
beneath it was a large quantity of pus. The state of the cerebellum 
was not reported. 

From the paucity of the notes vfhich accompanied the specimen, 
the cause of death was not quite clear ; but most probably there was, 
in addition to the other symptoms, disease of the cerebellum. 
Probably the life of this patient might have been saved, if a free 
outlet for the discbarge bad been effected at an earlier period. It 
IB important to notice to how great an extent the osseous sulcus 
lateralis was destroyed, without ulceration of the lateral sinus con- 
tained in it. In this respect the case is analogous to that of P. R. 

A case of a similar character to the lost was published by Mr. 
Gray, of St. George's Hospital, in the Transactions of the Patho- 
logical Society for the Session 1848-9. 

From previous remarks, it will have been gathered that the ex- 
istence of long-continued discharge from the ear of the affected side, 
is one of the most frequent symptoms attendant upon caries of the 
mastoid portion of the bone. This discharge is usually accompanied 
by perforation of the membrana tympani, although, as has been 
pointed out, the discharge usually comes from the surface of the 
meatus, and is purely sympathetic. The case which follows is of 
interest, from the fact that the membrana tympani was entire, and 
yet there was slight discharge from the ear ; and is further remark- 
able for the short duration of the chronic symptoms. It was pub- 
lished by Dr. Budd, of Bristol, in the year 1851, tq whom I am 
indebted for the preparation, and for several additional particulars. 

Cage VII. Catarrh of the mucous membrane lining the maitoid 
celU ; membrana tympani entire ; cariesof the petrous bone; abeceas 
in the cerebellum. — " George Bell, aged 13, of spare habit and deli- 
cate appearance, but never before the subject of serious illness, was 
laid up, in the beginning of June, 1851, with an attack, which was 
at first considered to be one of simple fever. Two circumstances 
were, however, remarked, which the sequel showed to be of great 



348 THE DISEASES OF THE EAR. 

importance. These were severe headaches, chiefly confined to the 
right temporal region, and a slight discharge from the right ear, 
with severe deafness on the same side. 

" For the relief of these complaints, leeches were applied to the 
temple and behind the ear, followed by a blister to the same spot. 
Salines and a few gentle doses of mercury were given internally. 
Under this treatment the pain abated, the febrile symptoms entirely 
subsided, and in the course of a few days the boy was able to return 
to school, and resume his usual occupations. The pain in the temple, 
however, never entirely ceased. It was described as a dull pain, 
occasionally attended with throbbing. Up to this period there had 
been no vomiting, and no disorder in the motor or other powers of 
the nervous centres. 

" On the 12th of June, he was again laid up, and on the following 
day Mr. Tribe, his usual medical attendant, was sent for. The 
pain in the head had once more become continuous and severe ; and 
was limited still more strictly than before to the right temple, occu- 
pying, according to the patient's own description, a space not 
broader than a crown-piece. It was not either acute or lancinating. 
There was still great deafness in the right ear, though the discharge 
had ceased. An entirely new symptom of great significance was 
now added. Two days previously, the speech had become thick and 
indistinct, and was now at times almost unintelligible. Mental 
faculties unimpaired ; memory accurate ; no strabismus ; no lateral 
or other deviation of the tongue ; no sickness ; pupils somewhat 
dilated, but equal and sensitive ; vision good ; no heat of surface ; 
no thirst ; extremities rather cold than otherwise ; tongue moist 
but thickly coated ; bowels torpid. Pulse about 100 in the minute, 
weak, and fluctuating. Complexion pale, and countenance deeply 
marked with the stamp of suffering. 

" On the following day, his gait was observed to be insecure, and 
there was a dragging of the right leg. The face was also drawn, but 
to which side was not noted. The pain in the head had extended 
itself across the forehead, and the patient had become drowsy. He 
had also vomited several times, rejecting everything as soon as taken, 
except milk, which sat well on the stomach. The bowels had been 
freely acted upon by an aperient, given the day before. 

" Under these circumstances, it was decided to put the patient at 
once under the influence of mercury, and employ extensive counter- 



THE MASTOID CKLLS. 



349 



irritation. With this view, three grains of blue pill were given every 
four hours, and a blister was applied to the nape of the neek, 

" On the following day, four grains of iodide of potassium were 
given with each dose of blue pill, and a blister was applied to the 
shaven scalp. 

" On the 16th, the pain had extended to the back of the head, and 
there was at times double vision. The vomiting and drowsiness con- 
tinued. 

" On the 17th, that is to say, the fifth day after the relapse, marked 
amendment set in. The pain had much abated, being felt, in fact, 
only when the head was moved ; the utterance had become more 
distinct, and the distortion of the features had disappeared ; the 
drowsiness had ceased, and the vomiting had become much less fre- 
quent. Thero was still, however, some slight thickness of speech, 
occasional double vision, and inequality of pulse. 

" On the 19th, he had so much recovered as to come down stairs; 
and on the 20th, he dressed himself and descended without help. 
During the greater part of this day, he amused himself with Lis 
pencil : and several complicated heraldic drawings, executed with 
a firm and clear outline, which are still extant, show, bettor than 
any other evidence, how entirely the right arm had recovered its 
loss of power. 

" Up to the 1st of July, the amendment had suffered no check ; 
and on that day the patient was down stairs, running about and 
quite cheerful. It is worth notice, that he occupied himself a good 
part of that day with a box of carpenter's tools, handling them with 
hia usual freedom and effect. 

" As the changes revealed by examination after death, coupled 
with the history already given, leave no doubt that at this time, one 
if not two abscesses of considerable size existed between the folds of 
the right lobes of the cerebellum, such an amount of recovery as this 
must be looked upon as a very remarkable circumstance; and as one 
which might readily lead an incautious practitioner to give a favorable 
prognosis. The only trace of cerebral disorder still remaining, was 
some slight thickness of speech. 

" The hopes excited by this favorable change were, however, swept 
away on the following day, the 2d of July, by a return of the former 
symptoms in still greater violence than before. 

" On the Sd of July I saw him for the first time, in consultation 



wilh Mr. Tribe, to whom I am chiefly indebted for the notes of 
case. 

" The condition of the patient waa then very striking, and charac- 
teristic of severe intercranial mischief. The pain in the head, at all 
times severe, way occasionally bo acute as to extort moans and cries. 
A very remarkable characteristic of the pain, was the intense degree 
to which it WHS aggravated by any, the slightest, movemeat of the 
head, voluntary or otherwise. The dread he showed at every each 
attempt, could not hu readily forgotten by any one who witnessed 
it. The chief seat of the piiin appeared to correspond with the base 
of the occipital bone on the right side ; although, in less severity, it 
affected the whole bead. Ilis brow was deeply knit, and his wholfl 
aspect bore the imprint of great suffering. lie was very drowsy 
withal, so that his whole time was spent in dozing or acute pun. 
lie yawned frequently ; bis pupils were much dilated, but equal and 
sensitive; and he was very intolerant of light. There was ao dis- 
charge from the right ear, with which he could hear the ticking of k 
watch several inches off. Everything in the shape of food or medi> 
cine was vomited as soon aa swallowed ; the pulse varied, being at 
the time of my visit only forty strokes in the minute. The belly 
was deeply sunken and retracted ; and the skin peculiarly dry and 
harsh. The graap of the right band seemed to be somewhat lees 
firm than that of the left, but there was no impairment or loss of 
motor power (in the way of parnlysis that is) in any other part. His 
mind was clear, and memory good ; and hia speech, though thick, 
was sufficiently intelligible. There had been no fit or convulsioii 
from the first. The urine was scanty, and of high specific gravity, 
throwing down on being boiled, a precipitate, which was immediately 
redissolved on the application of nitric acid. The tongue was coated 
with a thick yellow paste. From this time to the Tth of July, there 
was little change, except that the vomiting became gradually less 
urgent. On that day, to the surprise of all, he began, for the third 
time, to amend ; the pain in the head abated, the drowsiness lessened, 
and the sicknesa became lesa and leas frequent. From this time, he 
steadily improved, and on the 13lh of July waa so much better, that 
it waa agreed that I should suapend my visits for some days. The 
head was now almoat free from pain, he moved with ease and free- 
! dom, and the vomiting had quite ceased. His utterance became 
WIDucb clearer ; his tongue much cleaner ; he began to take light uou- 
K tiahment with relish ; and his bowels acted, for the first time, without 



STOID CELLS. 



351 



medicine. Although there was no derangement amounting to para- 
lysis, he had still a more perfect use of the left than of thif right 
arm ; feeding himself, for instance, by preference with the left hand. 

" On the 14th the patient was put in ft warm buth, which he 
much enjoyed ; and, on being taken out, stood for some time lean- 
ing for support on his father's shoulder. This amendment waa, 
however, of short duration. 

" On the following day he became much worse, and in the eonrse 
of it was several times seized with severe paroxysms of pain, lasting 
many minutes. During this time, the eyes were fixed, and the pupils 
gradually dilated more and more, till the agony passed into uncon- 
sciousncBB ; he then remained for some time in a state of deep stupor, 
from which he slowly recovered. Although there was no convulsion, 
each of these attacks was followed by great exhaustion. 

"From this period he lingered, with very little change and no 
new phenomena, until the 17th of July, when he expired rather 
suddenly, after one of the paroxysma just described. 

" The powers of the left hand and arm were unaffected through- 
out, with this single exception, that, for a short time on the tlth of 
July, the fingers -were spasmodically bent on the hand. He helped 
himself to a cup of coffee without difficulty with that hand about half 
an hour before his death. 

" The principal agents employed in his treatment were bitters, 
and mercury, both internally and by inunction. Latterly opiates 
were given to lull the pain, and alkalies for the sickness ; but the 
latter with little or no effect. 

" The body was examined twenty-eix hours after death. On open- 
ing the head, the ventricles of the brain were found to be enormously 
distended with perfectly transparent serous fluid, the quantity of 
which was not measured, but must have amounted to at least half a 
pint; one of the ventricles was in fact accidentally opened by the 
saw in removing the skull-cap, although the brain was by no means 
deeply wounded. The convolutions of both hemispheres were so 
much flattened by the pressure, that the sulci between them were 
entirely effaced. On pursuing the examination, the explanation of 
this state of things was found in the condition of the venie Galeni, 
which were flattened, and contained no blood ; the return of blood 
through them had been obstructed by the pressure of underlying 
disease, and dropsy of the ventricles had resulted. A few transpa^ 
rent and very minute granulations, which were only visible when 



352 THE DISEASES OF THE EAR. 

looked at obliquely, were scattered over the arachnoid at the 
base t)f the brain. With this exception, the state of the cerebral 
membranes, whether of the surface or ventricles, was perfectly 
normal ; they presented no trace of inflammation, and the structure 
of the brain itself was sound. The inferior surface of the right 
lobe of the cerebellum was attached to the dura mater by slight 
adhesions. On further examination, this lobe was found to be the 
seat of three distinct abscesses ; two of which were situated between 
a duplication of the deep folds which traverse the lower surface of 
the cerebellum. It is important to remark in reference to the his- 
tory of the case, that their presence involved no breach of fibre or 
other structure, although from their size they must have exerted 
severe pressure on the surrounding parts. One of them was about 
the size of a Spanish nut, the other would easily have contained a 
large walnut. Both were lined by a distinct membrane, of new for- 
mation, to which a somewhat thick layer of concrete pus was adhe- 
rent. These characters were best marked in the smaller of the two 
abscesses, which, if any inference may be drawn from such appear- 
ances, appeared to be the older of the two. The third abscess was 
still larger, and was formed at the expense of the substance of the 
cerebellum itself. The central part of the right lobe was almost 
entirely converted into pus, so that the whole of this lobe might be 
represented as a bag of matter whose walls were formed by gray 
substance. The small portion of white substance still remaining 
was broken up, and consisted chiefly of diflluent pulp. At one 
point, corresponding to the root of the rhomboidal body, a small 
extravasation had occurred. This abscess was lined by no mem- 
brane, and had no definite wall, the part in which the suppuration 
was complete shading ofi* gradually into broken-up nervous tissue. 
The pus it contained was also much more fluid than that of the 
other abscesses. From these characters there can be little doubt 
that it was the most recent of the three. The left lobe and other 
parts of the cerebellum were free from disease. On examining the 
interior of the skull itself, a yellow spot, about the size of a pea, 
was discovered over the petrous portion of the right temporal bone. 
The dura mater was here separated from the skull beneath by a thin 
layer of concrete pus lying upon the carious bone ; but there was 
no trace of inflammation or other disease in the cerebral aspect of 
the membrane. Over this space the bone was destroyed in its whole 
thickness, so that, on lightly scraping it with a scalpel, the cavity 



MASTOID CELLS. 



of the tympanum was brought into vipw. This cavity was fi11o<l 
with opaque lymph, of a reddish -yellow color, but on its removal 
the proper bones and muscular apparatus of the ear were seen to 
be still in place. The memhrana tympani was slightly thickened 
and opaque ; but with this exception was sound, as was also the 
meatus externus. It was ascertained that the tungs were free from 
tubercle, and the heart healthy; but the other viscera were not 
minutely examined." 

Upon carefully inspecting the bone, it was evident that this case 
formed no exception to the general rule laid down by rae, that when 
disease, beginning in the mastoid cells after the second or third year 
of life, injures the brain, the cerebellum is the part affected ; for it 
is clear that the part principally involved lies posterior to the small 
bones, and that it is in reality included in the mastoid cells. 

This case gives rise to one or two other important considerations : 
and first as to the duration of the disease of the ear. Dr. Budd 
informs me, that the earliest history he had of any affection of the 
ear was, that two months before the fatal illness, the boy had been 
kept from school for two days by a slight earache, but the attack 
seemed to go off. This attack of earache followed an. illness sup- 
posed to be scarlatina, and it is probable that the attack was the 
exciting cause of the urgent symptoms ; but considering the carious 
condition of the petrous hone, and the presence of the abscess in the 
cerebellum, there can, it appears to nie, be but little doubt that the 
disease, in a chronic form, had been in existence for a considerable 
period. In a letter to rae, Dr. Budd says : " II is difficult to find a 
satisfactory reason why a carious condition of the posterior part of 
the petrous bone should give rise to abscess in the cerebellum, and 
caries of the superior part to abscess in the cerebrum ; but it seems 
to me that the difficulties are fewer under the supposition that the 
disease is generally propagated by the veins llian under any other. 
In the case of George Bell, the notion of propagation by direct 
proximity was out of the question ; for not only was the carious 
bone at a considerable distance from the cerebellum, but no morbid 
change of any kind could be detected in the cerebral aspect of the 
dura mater covering the carious part. Many other reasons, if neces- 
sary, could be given for believing that in this and many similar 
cases, the veins were the channel of the mischief. That it should 
have had (as under this supposition it would) to run counter for 
some distance to the current of the ^dood is no real difficulty ; since 




854 

in the inflammation of the femoral vein which is set up bj disesMd 
conditions of the uterus, and still more bj intestinal ulcer, we hare 
undoubted and frequent examples of such a course : it would at the 
same time be going too far to deny that in some cases, especially 
where the abscess is seated in the brain, the disease is propagated 
by direct continuity." Several cases have been seen by me in 
which, in a spot exactly corresponding with the cerebral mischief, 
the dura mater was either ulcerated through, or manifestly diseased. 
From the peculiar discoloration of the parts in many such cases, I 
should suppose the putrefactive decomposition of the carious dis- 
charges has much to do in the extension of the disease. With 
regard to the mode in which the disease is propagated from the ear, 
there appears to me no doubt that the dura mater is affected hy 
direct continuity. To the lateral sinus there seems abundaut evi- 
dence that it is communicated by the bloodvessels ; and although it 
is impossible to disprove the statement of Dr. Budd, that the disease 
extends to the brain through the blood also, it has always appeared 
to me probable, that the existence of an abscess in the bone ha^ by 
sympathy caused a similar disease to he developed in the brain. It 
is quite certain that it does not take place by continuity, inasmuch 
as a considerable layer of healthy brain often intervenes betireen 
the petrous bone and the abscess in the cerebrum. 

I[ has been before stated, that disease of the mastoid cells 
duces death by causing suppuration of the lateral sinus, inflamm^ 
tion of the membranes of the cerebellum, or an abscess in the sub- 
stance of the latter; cases are, however, sometimes met with ib 
which the pneu mo-gas trie nerve is affected as it emerges through the 
foramen lacerum posterius. A case of this kind occurred to Mr. 
Coc, of Bristol, and was brought before the Bath and Bristol BrancL 
of the Provincial Association, in December, 1854. I give it in Ur^ 
Coe's words 

Case VIII. Di»ea»6 of the magtotd cells, advancing to the lattrtA 
»inu» and pneumo-gastrie nerre. — " An out-patient of the Brislol 
General Hospital came under my care, complaining of running at 
the right ear, which had existed for some years, and occasional 
paroxysms of acute pain in the ear and head whenever the dischargt- 
ceased for a time, such being the case at the period of application. 
Leeches were applied to the mastoid process, and warm fomentation! 
to the side of the head, and mercury was given internally. On 
next day symptoms of meningitis having come on, the patient 



THE MASTOID CELLS. 



355 



taken into the house. He progressed favorably for some days ; bnt 
afterwards began to complain of atiffnesa and pain in the right side 
of the neck, and sudden attacks of diflGcuIty of breathing, as if from 
spasm of the glottis. There was a distinct rope-like swelling de- 
scending from the base of the skull, down the aide of the neck, in 
the situation of the carotid sheath : it was very tender to the touch. 

" The diagnosis was caries of the posterior portion of the temporal 
bone; meningitis; obstruction of the right lateral sinus, either from 
extension of inflammation or from secondary purulent deposit ; sub- 
sequent coagulation of blood in the internal jugular vein; inflamma- 
tion of its sheath, with involvement of the pneumo -gas trie nerve, 
especially the inferior laryngeal nerve (the phenomena of the irrita- 
tion of this branch, being, at any rate, more manifested than of any 
other portion of the nerve}. 

" The correctness of the diagnosis was proved by the post-mortem 
examination." 

Mr. Leonard, of Bristol, brought forward a case at the same 
meeting, in which the pneumo-gastric nerve was implicated, and it 
is interesting to find that the cases of these gentlemen are considered 
by them corroborative of the opinion advanced by me, "that the 
parts of the encephalon, secondarily affected in caries of the petrous 
part of the temporal bone, vary according to the situation of the 
caries." 

In concluding this account of the pathology of the mastoid cells, 
let me glance at a peculiarity sometimes met with in these cases, 
viz., their being attended with symptoms exactly resembling remit- 
tent fever. 

Dr. Griflin, in the Dublin Journal of Science, published two cases 
of the kind. One of them, which is also cited by Dr. Watson, is as 
follows : — 

A young man, previously healthy, was attacked with fits of shiver- 
ing, accompanied by pain in the left side of the head. At first the 
paroxysms were rather irregular, but they soon assumed the form 
of tertian ague, coming on every other day, at about the same hour ; 
the cold fit commencing at noon, and lasting about half an hour, 
followed by a hot stage of somewhat longer duration, and termina- 
ting in a profuse sweat. In the intermissions the pain in the head 
was trifling ; there was no thirst nor heat of skin, but he did not 
sleep. A tumor formed over the mastoid process of the left side, 
and was opened, and a. quantity of extremely ofl'ensive brownish pus 



356 THE DISEASES OF THE EAK. 

sprang out with great force. This gave much relief. The bone 
was carious over a space as large as a shilling. After about ten 
days, the pain in the head and in the mastoid process became very 
severe ; the patient had violent shivering fits many times in the day, 
great thirst, heat of skin, vomiting, and delirium; his face was 
flushed, and his pulse hard ; and he died within a few hours of the 
accession of these last symptoms. / 



({?.) NECROSIS OF THE MASTOID PROCESS. 

On account of their position and peculiar arrangement, disease of 
the mastoid cells is usually of a more serious character than disease 
of the tympanum. The difierence between the construction of these 
cells in childhood and in the adult has been already described, and 
it will have been seen that in each period of life, during disease, 
there is scarcely any possibility of the whole of the secreted matter 
being discharged from the ear. 

In childhood, before the mastoid process is developed, the rudi- 
mental cells, as stated, are placed posteriorly and superiorly to the 
tympanic cavity, and are bounded externally by a portion of the 
squainous bone. In the instances already detailed of disease occur- 
ring in these cells during childhood, it has been shown that it 
advanced rapidly until it caused the death of the patient ; indeed, 
in those cases the brain, or its membranes, were most probably 
affected long before the patient's friends applied for relief, and be- 
fore the diseased portion of bone had become detached, or partially 
detached, so as to admit the free egress of the matter from the 
mastoid cells. An examination of a specimen illustrative of this 
branch of the pathology of the subject will show, that had the por- 
tion of necrosed bone, forming the outer wall of the mastoid cells, 
been capable of removal during the life of the patient, the progress 
inwards to the brain would probably have been arrested or averted. 
In the majority of cases of necrosis of the mastoid process which 
fall under notice among the out-patients of St. Mary's Hospital, 
the portion of necrosed bone does become detached before the mem- 
branes of the brain are affected, and frequently the mass of bone 
comes away with but very slight cerebral disturbance. Indeed, as 
a rule, when the portion of necrosed bone is detached, although it 



THE MASTOID CELLS, 



I 



may be of considerable size, tlicre is very little fear of injury to the 
brain or the dura mater. 

It is not always very easy to diatinguish between disease iu the 
tympanic cavity and that occurring in the mastoid cells. As a 
general rule, when the mastoid cells are affected, the pain is referred 
to the region of the mastoid process, or to the back of the head ; 
tenderness is experienced upon gently tapping or pressing upon the 
mastoid process ; the attacks of pain and giddiness appear more in 
the shape of sudden paroxysms, and the giddiness is more violent. 
It not unfrequently occurs that there is no perforation of the mem- 
brana tympani, though the disease in the mastoid cells causes irrita- 
tion and catarrh of the dermoid meatus. 

The following particulars relate to what may be considered one 
of the most favorable case* of caries of the mastoid process, 

Clironic catarrh of the mucous membrane lining the vtastoid cells; 
caries of the bone; removal of the dead portion; recovery. — Master 
W., aged 6, was brought to me on the 4th of September, 1853. " 
His mother said, that four years previously he had an attack of 
scarlet fever, followed by discharge from both ears, and by diilness 
of hearing. After the discharge had continued for three months, 
with pain at the back of the head, and frequent giddiness, an abscess 
formed behind the right ear, which being laid open, a portion of 
dead bone was felt, which gradually became detached and was re- 
moved. The discharge from the ear continued. On examination 
of the right ear, the membrana tympani was absent, and the meatus 
contained polypi. In the left ear, the membrana tympani was per- 
forated ; the mucous membrane of the tympanum was red, and 
poured out an abundant discharge. Posterior to this ear was a 
small orifice, through which, by means of a probe, dead bone was 
felt. This was the upper part of the mastoid process, which, by 
slow degrees, was detached and removed. After its removal, and 
the constant use of the syringe and warm water, the discharge dis- 
appeared. 

A largo number of cases, very similar in detail to the above, 
might bo added. Sometimes the head-symptoms are slight, at others 
very marked. There is usually polypus in the meatus, resulting 
from the irritation of the dead bone. If it seriously interferes with 
the outward progress of the dead bone, the polypus maybe removed ; 
otherwise it will generally be found to disappear after the discharge 
of the bone. In many cases which have fallen under my notice, the 



S58 



THE DISEASES OF THE EAR. 



portion of necrosed bone lias been removed from the meatus, wlthont' 
any incision being made over the mastoid process : a plan which 
may usually be adopted, since the membranus meatus ie capable of 
being greatly dilated, and the disfigurement is thus less tHan wbeic 
an incision is made. 

It not unfroquently happens, that the loss of a considerable por- 
tion of the mastoid colls is unattended with any more serious dtmi* 
nution of the hearing power than that accompanying simple catarrh 
of the mucous membrane of the tympanum, accompanied by paj-tiU 
or complete loss of the membrana tympant. Paralysis of the portio 
dura nerve is, however, a not uncommon result. This nerve, it will 
be remembered, passes internal to the mastoid process, and is apt 
to become involved in the disease of the bone, as in the following 
cases. 

Catarrh of the mueous membrane of the tympanum and meutotd 
cells after soarlet fever ; caries of the mastoid process; paralysis cf 
the portio dura nerve. — Master C, aged 5, was brought to consult 
me on the 8th of February, 1853. His history is, that seven 
months ago he had an attack of scarlet fever, which was followed, 
a fortnight after, by a discharge from each ear, the loss of the small 
bones, and complete deafness, so that he does not hear a BOund. On 
examining the right ear, the membrana tympani and ossicles were 
absent, the mucous membrane of the tympanum was red and thick, 
and pouring out a copious discharge of mucus. 

JLeft ear. — The meatus contains a large polypus, below which is 
portion of necrosed mastoid process, that moves on being touched 
with a probe. The left portio dura nerve is paralyzed. The course 
of treatment recommended consisted in the use of a syringe and 
warm water daily, and in the administration of tonic medicines. 
In the course of a fortnight, the portion of dead bone gradually 
worked its way to the orifice of the meatus, and was removed ; it 
was about half an inch in length, and a quarter of an inch in 
breadth. After the bone was extracted, the polypus disappeared, 
and the discharge ceased. 

Sometimes, as in the next case, the cerebral symptoms are of 
great severity. 

Caries of the mastoid cells; severe cerebral symptoms; paraiytit 
of the portio dura nerve. — Miss J. S., aged 6J, pale and sickly, was 
brought to me on the 14th of August, 1850. Iler mother stated, 
that a day or two after ber birth a discharge was seen to issue from 



THE MASTOID CELLS. 



359 



the tube of each ear, but more abundantly from the left. The right 
ear recovered, except a alight occasional discharge, but it waa con- 
stant on the left side ; and at the age of two years was followed by 
an abscess at the back of the ear, accompanied by violent pain in 
the back part of the head, giddiness, and partial insensibility. 
After the abscess had remained open between two and three 
months, a rounded portion of dead bone, of the size of a large 
horse-bean, came away, and about this time the child lost the use of 
the muscles of the left side of the face. When seen by me, there 
was so great a dulnesa of hearing that she had to be loudly spoken 
to within the distance of a yard. The membrana tympani of each 
ear was absent; the tympanic mucous membrane was red and thick, 
and there was a. depression behind the left ear, from which the piece 
of dead bone had been removed. The treatment pursued consisted 
in the use of frequent injections with warm water, followed by mild 
astringents. Gentle counter-irritation was kept up behind each 
ear, and tonic medicines administered. Under these plans the 
discharge gradually subsided, and the power of hearing somewhat 
improved. 

Treatment in the adult. — la the adult, the mastoid process rarely 
comes away in a considerable portion ; and the outer surface is so 
dense, that the only way in which discharge escapes from the inte- 
rior is through a small fistulous orifice. The inner wall of the mas- 
toid cells is Qsually the first to yield, and the sulcus lateralis is 
partially or wholly destroyed, as haa been shown by cases already 
quoted. The cause of the inward progress of the matter is, doubt- 
leas, the difficulty of its escape outwards. In some cases where the 
membrana tympani has been wholly destroyed, and where the 
mucous membrane of the tympanum is not so thick as to close or 
very much diminish the aperture from the mastoid cells, a certain 
quantity of the matter can escape through the tympanum into the 
meatus ; but often the membrana tympani is either entire, or, as in 
one case already cited, its lower margin is attached to the promon- 
tory, and effectually precludes the escape of the discharge. 

It is unnecessary to repeat the remarks already made as to keep- 
ing an opening in the membrana tympani. When that membrane 
is evidently preventing the egress of the matter, and where the irri- 
tation produced by the operation is not to be feared, there can be no 
harm in trying the effect of a puncture. Perforation of the mastoid 
process also suggests itself, and this operation may, doubtless, be 



360 TUE DISEASES OF THE EAB. 

performed in those cases where the matter is pent up in the cavity 
of the ear, and is causing such urgent and serious symptoms, as are 
likely, if not relieved, to terminate in death. I have never per- 
formed this operation, but I should not scruple to do so in a case 
where the life of the patient was threatened. Considering the large 
extent of the mastoid cells, it appears to me, that the best plan of 
operating would be to use a trephine over the middle and posterior 
part of the process, and to remove a portion of bone three-quarters 
of an inch in diameter. It might be imagined, that when the dis- 
ease has advanced so far as to produce coma, all attempts to give 
relief by making an outlet for the matter would be ineffectual. 
Such, however, is not the case ; for in one instance related by Dr. 
Abercrombie, a young lady, who had laid for three or four days in 
a state of perfect coma, and whose situation was considered to be 
perfectly hopeless, was immediately and permanently relieved by a 
sudden discharge of matter from the affected ear. Dr. Abercrom- 
bie adds, "It is, however, by no means certain, that in such a case 
as this, the discharge came from the cavity of the cranium ; for 
there is reason to believe that extensive suppuration within the 
cavity of the tympanum is capable of producing symptoms of great 
urgency, especially if there should be any diflSculty of finding an 
outlet." 

The treatment, however, on which it seems to me safest to relv 
for promoting the absorption of the matter and preventing its secre- 
tion, so as to bring back the ear to a more healthy condition, is 
counter-irritation, combined with plans for improving the general 
health. The following case thus treated is one of great interest, as 
from the symptoms manifest when the patient was first seen by me, 
there is no doubt that both dura mater and bone were affected. 

DiseaBc of the mastoid cells ; giddiness ; great pain in the head ; 
cured by the use of a seton, — R. D. M., a clergyman, aged 42, tall 
and thin, and not robust, consulted me on the recommendation of 
Professor Miller, of Edinburgh. The history of the case is, that 
since a child, after an attack of earache, has had discharge at times 
from the left ear until the age of 24 ; from 24 to 32 had but one 
attack of pain and discharge; between 32 and 85 had several severe 
attacks of pain at intervals of a few months ; at the age of 35 had 
a severe attack of pain, after which such attacks became frequent, 
and the discharge became constant and fetid ; at times serous, at 
others purulent or bloody. By degrees fits of confusion and giddi- 



THE MASTOID CELLS. 861 

ness in the head supervened, leading to prostration of nervous 
energy, and a constant feeling (to use the patient's words) " as if 
he were on the brink of apoplexy.** 

About four months previous to consulting me, he exerted himself 
greatly in preaching on one occasion. On the same evening, he 
afterwards sat listening long to a speaker in a public debate, with 
his head resting on his right arm. On rising up, he was seized with 
giddiness and a numb feeling in the right arm, while his pulse was 
slow and laboring. He got home with difficulty; but, under the in- 
fluence of rest and gentle purgatives, he speedily recovered. About 
two months afterwards the giddiness returned, but in a more persis- 
tent form, accompanied by double vision. He had a foul tongue, 
palpitation, and flatulency ; and there was a fixed pain in both sides 
of the forehead over the frontal sinuses. The ordinary discharge 
from the ear continued, and the numb feeling in the right arm re- ^ 
curred, extending from the elbow to the fingers, and following accu- 
rately the course of the ulnar nerve. At this time he was treated 
with blisters behind the cars, but without much relief. A month 
before the patient came to me he was under the immediate care of 
Professor Miller, who stated that he was then relieved by food and 
stimuli and the administration of tonics. In a day or two the symp- 
toms assumed a pericranic character ; they were also intermittent, 
aSiecting the left side of the forehead, eye, and face, and were unac- 
companied by stuffing of the nostril on that side. The treatment 
was then changed to Fowler's solution, with an anodyne embroca- 
tion ; and in ten days the pain, giddiness, and uneasy feelings in 
the arm all passed away. At the time of my seeing him he com- 
plained of occasional swimming in the head, pain in the ear, and 
fetid discharge, together with a sensation at the back of the left ear 
when he walked, as if there were an empty drum there — a sensation 
which was increased upon tapping the mastoid process. The pain 
extends over the head from ear to ear, and also over the back part 
of the head ; and when the discharge is very abundant, he suffers 
from the extreme sensitiveness of a spot three inches posterior to 
the upper part of the ear. When he presses upon the left jugular 
vein, he feels a great weight at the back of the ear, as if something 
would burst. 

On inspection, the surface of the meatus was observed to be red 
and denuded of epidermis ; the upper and only visible part of the 
membrana tympani was also red, and evidently fallen inwards to- 



STOID CELLS. 



361 



nesB in the head superveucd, leading to prostration of nervous 
energy, and a constant feeling (to use the patient's words) " as if 
he were on the brink of apoplexy." 

About four montlis previous to consulting me, he exerted himself 
greatly in preaching on one occasion. On the same evening, he 
afterwards aat listening long to a speftkcr in a public debate, with 
his head resting on hia right arm. On rising up, he was seized with 
giddiness and a numb feeling in the right arm, while hia pulse was 
slow and laboring. He got home with difficulty; but, under the in- 
fluence of rest and gentle purgatives, he speedily recovered. About 
two months afterwards the giddiness returned, but in a more persis- 
tent form, accompanied by double vision. He had a foul tongue, 
palpitation, and flatulency ; and there was a fixed pain in both sides 
of the forehead over the frontal sinuses. The ordinary discharge 
from the ear continued, and the numb feeling in the right arm re- 
curred, extending from the elbow to the fingers, and following accu- 
rately the course of the ulnar nerve. At this time he was treated 
with blisters behind the ears, but without much relief, A month 
before the patient came to me he was under the immediate care of 
Professor Miller, who stated that he was then relieved by food and 
stimuli and the ailministration of tonics. In a day or two the symp- 
toms assumed a pericranic character ; they were also intermittent, 
affecting the left side of the forehead, eye, and face, and were unac- 
companied by stuffing of the nostril on that side. The treatment 
was then changed to Fowler's solution, with an anodyne embroca- 
tion ; and in ten days the pain, giddiness, and uneasy feelings in 
the arm all passed away. At the time of my seeing him he com- 
plained of occasional swimming in the head, pain in the oar, and 
fetid discharge, together with a sensation at the back of the left ear 
when he walked, aa if there were an empty drum there — a sensation 
which was increased upon tapping the mastoid process. The pain 
extends over the head from ear to ear, and also over the back part 
of the head ; and when the discharge is very abundant, he suffers 
from the extreme sensitiveness of a spot three inches posterior to 
the upper part of the car. When he presses upon the left jugular 
vein, he feels a great weight at the back of the ear, as if something 
would burst. 

Ou inspection, the surface of the meatus was observed to be red 
and denuded of epidermis; the upper and only visible part of the 
membraoa t^ympani was also red, and evidently fallen inwards to- 



864 



THE Diseases of the eab. 



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THE DISEABE6 OF THE EAR. 



It is true that many persons live long, having bad, daring the 
whole of life, a discharge from the ear without any disea«o of the 
hone : others live many years with a discharge, but at death the 
bone and dura mater are found atfected, and might under many cil 
cumstanccs have assumed an active form of disease, ending in death. 
It is important, therefore, to be able to form an opinion respecting 
cases of the kind. To do this, it is first necessary to decide upon 
the source of the discharge. If it arises from the dermoid meatus, 
the menibrana tympani being entire, there is, as before stated, most 
probably irritation in the tympanic cavity or mastoid cells, of which 
irritation the discharge is the symptom. Unless there were simplj 
some eczematou3 state of the meatus to account for the discharge^ 
and unless the hearing power were perfect, such a case should be 
looked upon with suspicion, especially if attended with any symptomt 
of brain or cerebral irritation. Again, if the discharge issues from' 
the tympanic cavity through a small or a valvular opening, and it 
ia requisite to blow the nose forcibly to clear out the tympanum, 
there probably is, or will be, some affection of the bone, from the 
accumulation of the discharge. If there is a large orifice in th« 
membrana tympani, or that membrane is absent; if there is no ulcer- 
ation of the mucous membrane of the tympanum; if there is some 
power of bearing remaining; and if by pressing and tapping the 
region round the ear, no pain is felt ; end if there are no other symp- 
toms of disease in the ear or head, I think it may be assamed tbst 
there is no disease of the bone ; and that by attention to dsilr 
syringing, and the other plans alluded to when speaking of the 
treatment of Ithese affections of the ear, there is a fair prospect of 
the disease remaining confined to the mucous membrane of the ea 
On the other hand, it becomes a duty to state that any negligen< 
on the part of the patient, by which the discharge should be allowe4' 
to collect so a3 to fill up the orifice in the membrana tympani — a, blow 
on the ear, an attack of fever, or any severe illness, might caose aa 
irritation in the ear, which, if unattended to, might advance to thi 
bone. 



CHAPTER XV. 



THE DISEASES OF THE NERVOUS APPARATUS OF THE EAR, PRO- 
DUCING WHAT IS USUALLY CALLED "NERVOUS DEAFNESS." 



The nervous apparatus wliich receives the sonorous undulations 
from the tympanum, and conveys them to tho brain — one of the 
most delicate structures in the human body — ia liable to many func- 
tional and organic derangements.' As some cases of deafness depen- 
dent upon the derangement of the nervous apparatus connected with 
the organ of hearing, appear to be caused by the condition of the 
brain generally, or of that part in intimate relation with the acoustic 
nerve, it has seemed desirable to divide the nervous diseases of the 
ear into two classes : to the Jirst of which belong those cases where 
the special nervous apparatus of the organ ia alone affected ; to the 
tecond, those where the brain conjointly with the ear, seems to be 
injored. 

The first class may be aubdivided into diseases arising from — 

(1.) Concussion. ^ 

(2.) The application of cold. 

(3.) Various poisons : as that of typhus, scarlet, or rheumatic 
fevers, of measles and mumps, of gout, of an accumulation of bile 
in the blood, and of quinine in large doses. 

And the second into diseases arising from — 



■ As I tuT* oothmg to add to the deKrJptioi 
rlnth, I hiiTB nut aotend apon Iha mlfject. 



r of (be Iab7- 



368 THE DISEASES OF THE EAR. 

(1.) Excess of mental excitement. 
(2.) Physical debility. 



(a.) DISEASES IN WHICH THE EAR ALONE IS AFFECTED. 

This section will be occupied with a review of the various kinds 
of disease comprehended under the first of the above classes, all of 
which are usually accompanied by more or less of congestion. 



(1.) Debility of the Nervous Apparatus of the Sar produced by 

Concussio7i. 

Concussion may arise in three ways ; either from a blow on the 
ear, or from the effect of loud sounds, or from a jar of the whole 
frame. Affections of the nervous apparatus of the ear, as the 
result of blows on the external organs, are not very common, since, 
as a general rule, the membrana tympani gives way and is ruptured, 
and consequently the shock on the drum is so far modified in its 
efiect on the ossicles and the fenestra ovalis, that the contents of 
the labyrinth receive no greater injury than that which causes a 
slight dulness of hearing for a few days. 

Cases of more permanent injury to the acoustic nervous apparatus 
do, however, sometimes happen from the effects of a blow on the ear, 
as in the following case. 

Injury to the nervous apparatus of the ear, j>^oduced by a blow on 
that organ, — A physician in London, while playing with his little chil- 
dren, suddenly brought his right ear in contact with the head of 
one of them, causing a rather severe concussion on that side of his 
own head. The concussion was instantly followed by a singing in 
the cars. I saw the patient soon after the accident, but could 
detect no unnatural appearance in the membrana tympani ; and on 
carefully testing the hearing power by the watch, there appeared to 
be no dulness of hearing. This physician has been seen by me from 
time to time since the accident, and ho tells me the singing remains 
as it was on the day the concussion took place. 

The nervous apparatus of the ear is frequently injured also from 
the effect of a general concussion of the body, in which case the 
hearing power is often entirely destroyed. The well known in- 



NERVOUS DEAFNESS. 



I 



stance of the late Dr, Kitto, who was rendered wholly deaf by a 
fall from the top of a house when a boy, may be noticed in illustra- 
tion, and some others follow which have fallen under my own obser- 
vation. 

Fatal deqfnegg m the right ear, and partial deafntaa in the left, 
following a fall from a horse. — The Rev. B, F., aged 53. During 
many years bis hearing has been dull during a cold. Five years 
before seeing me, he had a fall from his horse, and the fall was fol- 
lowed by a discharge of blood from the right ear for the space of 
two days, and subsequently of matter. For some days after the 
accident, the air whistled out of his right ear whenever the nose was 
blown. Since the accident, the right ear has been entirely useless, 
and the left so deaf that ho has to be loudly addressed within u 
yard nf that ear. There has also remained a constant singing noise 
in the head. On inspection, the hearing of the right ear was found 
to have been wholly destroyed, and the raembrana tympani pre- 
sented an orifice, the margins of which were opaque and uneven. 
Left ear. — The merabrana tympani was dull on its surface, and in 
parts calcareous. 

In some instances, slight amelioration of the deafness following 
the accident takes place, as in the next case. 

Total deafnegg in the right ear following a fall from a phaeton ; 
gradual improvement. — The Rev. J. L., aged 35, had a deafness in 
the right ear during a cold four years ago. In the same year he 
fell from a phaeton, and was unconscious for some days. When he 
recovered his sensibility, he found that there was a hissing sound, 
like that from a teakettle, in the right ear, which was completely 
deaf. During two years, however, subsequent to the accident, the 
power of hearing gradually improved, so that the patient is able to 
hear a loud voice with that ear. The noises still continue, and arc 
aggravated by wine, or by bodily or mental fatigue ; when writing 
or studying, these noises become overpowering, hut in the morning 
are much lessened. On inspecting the right ear, the air is distinctly 
heard by me to enter the tympanic cavity, but the patient experi- 
ences no sensation in the ear when it enters. A loud ticking watch 
IB heard. When spoken to through a trumpet, loudly and slowly, 
the voice is heard, but not till a second or two after the word has 
been uttered. The membrana tympani was opaque. 

The violent shock communicated to the nervous system of the ear 

(most probably through the medium of the membrana fenestrse ro- 

24 



370 



THE DISEASES OF THE 1! A R. 



tundic) in the act uf coughing, Bometimes produces deafoew; 
deed, iu some cases, hooping-cough seems rather to cause deafneM. 
by this means than by the agency of poison. 

Nervous »y»Unn of the car injiird hy violent coughitiff. — Mrs. . 
consulted me in 1851, and stated that a week previous to her vwi, 
directly after coughing, she experienced a pain in the left ear, whldl 
lasted for two hours, together with a loud singing noiac which 1 
never ceased. She complains of an unpleasant sensation M j 
sounds passed through the ear, and is troubled with a sense of giddi 
ness, and a feeling of confusion in the head. Every step she take 
sounds like the beating of a drum. The membrana tympaui i 
fallen in, and its surface dull. The watch was heard only whoa i 
contact with the ear. Means having been used to diminish the c 
gestion of the nervous apparatus of the ear, the distressing i 
toms of nervousness and giddiness disappeared, but the singiiu 
sounds remained. 

The concussion upon the nervous system of the ear resulting froa 
loud sounds is a very common cause of deafness. In a prcviouE p 
of this volume, when speaking of the functions of the ossicles an 
muscles of the tympanum, it was shown that the one use of 1 
tensor tympuni muscle is to render tense the membrane of t 
fenestra rotimda, ns well as that of the larger membrane; and u^ 
this tense condition the meinhrune of the fenestra rotunda is tfarowi 
into vibratory movements of much less extent than when it is in i 
rela.xed state. When u loud sound is anticipated, the tensor 1 
pani muscle draws the memhrana tympani and the membrana fenei 
trie rotundie tense ; so that, when the approach of a loud sound i 
expected, it rarely injures the ear. On the contrary, however, wbffl 
both membranes are comparatively lax, the same sounds throw thd 
into very extended vibrations, and the fluid in the cochlea by th 
magnified movements of the membrana fenestrae rotundse is so c 
cussed as to injure, and often most seriously, the expansion of t 
auditory nerve in the labyrinth. 

Injury to the nervous apparatus of the ear may be produced by i 
variety of sounds. Oases have been seen by me in which a cannon- 
ade at land or sea, or the firing a single cannon, has produced I 
injury ; and others have occurred where an explosion of gas, thundeTi 
a pistol shot, or even loud shouting near the ear, have resulte<I ii 
the same effect; but the most common cases are those which folloT 
the long-continued qiort of shooting, where the deafness almost it 



NERVOUS DE 



I 



Tariably occurs in the left car, which is turned towards the gun 
during its explosion, and consequently receives the direct concussion. 

The treatment 'm recent cases when the patient is suffering from 
the immediate effect of the shock, consistB in the removnl of the con- 
gestion by the application of leeches, or by capping ; by the admi- 
niatration of mild aperients; by strengthening the general nen-ons 
system as much as possible, and by securing the ear against the 
effect of loud sounds. 

JVotees in the ears, deafness, and a feeling of deadncss in the ketid, 
following the sound of a pistol shot ; relief. — Mr. C. S., aged 45, a 
fortnight before consulting me, fired a pistol, for the first time in his 
life, in the open air on a cold frosty day. The concussion was in- 
stantaneously followed by a hisslnf; Doise in each ear, but more espe- 
cially in the right, and he also felt a shock throughout the whole of 
the bead, followed by a " feeling of deadneas" in it. Since the acci- 
dent, ho has been dull of hearing, and has observed, among other 
things, that he could not hear the " ring of money." Leeches and 
mustard plasters were applied behind the ears, and small doses of 
calomel and colocynth were adminiaterod. Immediate relief to the 
head and cars followed the application of the leeches, and in a week 
the bearing had improved, and the noises diminished. 

Nervous apparatus injured by the report of a cannon. — W. L. C, 
Esq., aged 73, about four months before consulting me, his hearing 
being then perfect, was sitting in the open air at Brighton, looking 
upon the sea, when a cannon near where he sat was fired, without 
his having any idea of such a proceeding being about to take place. 
The concussion was immediately followed by a singing in the ears, 
or rather about two yards from them, and a sensation as if water 
were rushing through them. Since the accident, he has heard a 
whisper very distinctly, but a loud voice causes unpleasant jarring 
sensations in the ears, and deafness to all sounds. In another case, 
the ear was ".benumbed" for some time after the patient's child had 
shouted into it. 

Nervous apparatus of the ear injured by very loud shouting ; very 
distressing noises ; great relief. — When surgeon to the St. George's 
and St. James's Dispensary, a poor man applied to me for relief 
from deafness and very distressing noises in the left ear. The 
latter had lasted several years, and the patient, a strong muscular 
man, thinks they were caused by the loud shouting he is obliged to 



872 



THE DISEASES OF THE EAB. 



practice as a Iiawker of fish. These noises came on in the left ear, 
and after remaining tliere some time ailvanceil to the left side of 
the head; they have increased lately, sometimes resembliag "'i 
rapid tinkling," at others being like the driving of a sledge ham- 
mer ; but most commonly they resemble the roaring of the ses. 
When at their loudfist, as after exertion, the house seems to go 
roond with him. The ear is quite insensible to any sound hat that 
of these noises. The right ear is healthy. On examination, the 
membrana tympani of the affected ear was found to be opaque, and 
the air passed through the Eustachian tube with a loud crackling. 
As this was a local alTection, as the patient was a strong man, aui 
as the symptoms were increased by any cause which increased a flo<r 
of blood to the organ, I determined to treat the case as one of con- 
gestion, and accordingly ordered the patient to apply twelve leeches 
below the ear, followed by a cantharidine cerate dressed with nngtt- 
entum hydrargyra, at the same time that the outer half of the 
meatus was washed with a solution of nitrate of silver sufficiently 
strong to produce desquamation. This was followed by the use (^ 
a solution of chloride of zinc (six grains to the ounce) to the t 
fas, so as to cause a discharge. The result of this treatment wM 
satisfactory. The noises, the patient says, " have not been bo louA 
or nearly like it:" and ten days subsequently to this report, he 
said that his head was much better, and '^ he could do his work with- 
out being obliged to give up." 

Nervous apparntus of the ear injured by the explosion of Haddert^ 
of gas. — J. B., aged 64, was admitted under my care at St. Mary' 
Hospital in 1853. He stated that nine months previously, directly 
after the explosion of two bladders of gas at the distance of a yard 
from his head, he suddenly became so hard of hearing, that he could 
not hear a voice except when spoken to distinctly at a distance of 
two yards from the head. The explosion was followed by a singing 
sound in the ears, which gradually subsided. The watch could not 
be heard at a distance of more than two inches from the right ear, 
and only when in contact with the left. The treatment consisted ia 
the application of leeches below the ears, but the patient did Dot 
return to report progress. 

The following is a well-marked case in which the nervous appa- 
ratus was injured by shooting. 

J)eafness in the left ear following shooting, and temporarily in- 
creased by a dag's apart. — F. F., Esq., aged 23, accustomed to 



SERVODS DEAFNESS. 3l3 

shoot, has been gradually becoming dull in the left ear. For two 
years he has not been able to hear general conversation distinctly, 
and the striking of the clock seems no longer attended by the natural 
sound. Is more dull of hearing during a cold. Is not aware of 
any cause that could have produced the deafness. The right ear 
was in a natural state ; hy the left the watch was only heard at the 
distance of half an inch. The treatment consisted in the use of 
gentle counter-irritants over and around the ear, and in doing all 
that could be suggested for diminishing local and general conges- 
tion. This treatment was followed by great improvement at the end 
of about three weeks, when the watch could be heard at a distance 
of four inches — an improvement which continued, with the excep- 
tion of a considerably increased amount of deafness which ensued 
upon a morning's shooting. This increased deafness continued for 
some days, and then gradually diminished. The last time the patient 
was seen by me, the hearing had not regained the previously im- 
proved state, for the watch could only be heard in contact with the 
ear. 

Hot having had the opportunity of ascertaining the condition of 
the ear by the aid of dissection, I have assumed that in these cases, 
arising from shooting, the nervous system of the ear is defective, 
The grounds of this conclu.iion are, that the noises and defective 
hearing followed immediately on the concussion, and all the symp- 
toms indicated that a shock had been given to the nervous system. 
The secondary effect of this concussion, it can scarcely be doubted, 
may be anchylosis of the stapes to the fenestra ovalis. In cases, 
indeed, when the nervous system of the ear has received a very 
severe concussion, and deafness has eubseqnently slowly come on, I 
have convinced myself of this anchylosis hy dissection, and will 
now relate one or two cases of the kind. 

Coneuesioii of the nervout apparatus of the ear hy thunder; com- 
plete deafness. — T. D., aged 80, is so completely deaf that he can- 
not hear any sound. He states that, fifteen years ago, when in a 
thunder-storm on the coast of Guinea, he was rendered thoroughly 
deaf by a clap of thunder, and since then haa not heard a sound. 
On examination, an orifice was observed in each membrana tym- 
pani. No treatment was attempted, hut about two years after the 
examination, the opportunity was given me of dissecting his ears, 
which were in the following morbid condition. 

Right ear. — At the posterior part of the membrana tympani was 



374 THE DISEASES OF THE EAR. 

an orifice about two lines in diumeter, the remainiog portion of tb» 
membrane being white, thick, and tense, and more concave ( 
n ally than natural: parts were also calcareous. In tlie centre of 
the remnant of the mcmbrana tympani is a space about half a line 
in diameter, in which the epidermoid, dermoid, and mucous layers 
alone remain. The long process of the incus and the crura of the 
stapes are gone, and the expanded base of the atapea is at,tached tt> 
the fenestra ovalia more firmly than natural. The membranoos 
labyrinth was atrophied, and the nervous fibrillic of the cochlea 
appeared the same. 

Xcfl! ear. — Like the right ; except that the crura of the stapes 
were only partially absorbed. 

In another case of total deafness produced by a loud cannoQading,' 
the only morbid condition that could be detected by me, on disseo* 
tion, was that the otoconio was more abundant than natural, whila 
in the vestibule there was a deposit of oval-shaped cells. 

Results similar to those noticed as following the practice of shoot- 
ing, also occur to operatives engaged in occupations involving very 
loud sounds. Thus in a large factory for making steam-boilers, I 
found a great number of men engaged in riveting the holts, an(l 
therefore obliged to work inside the boiler, who were very deaf, 
will be very interesting to ascertain by post-mortem inspection the 
pathological condition of the ear when subjected to such loud 
sounds, and some day perhaps the opportunity will be afforded me 
of doing so. 



(2.) The effect of the (tpplication of 
of the c, 



•■old on (he nervoii» ap. 



There are two classes of cases in which a diminution of the tem^ 
perature is found to be injurious to the ear : Jn the one cold air, in 
the other cold water, is the agent producing the effect. I have 
known engine-drivers to suffer from deafness after being exposed to 
a cold blast, and huntsmen also who have had a sudden *' check' 
when very hot, and have then stood about while a bitter east uritul 
was blowing upon them. The effect of the application of ooli 
seems, in the first instance, to produce congestion ; and then t< 
lead to the symptoms of noiae in the ear and of deafness, whid 
appear to depend opoQ a depressed or depraved action, sabsequeD 



NERVOUS DEAFNESS. 



375 



to and resulting from the congestion. In wbat the depraved action 
consists, it is, however, difficult to determine. The congestion often 
yields to the application of leeches ; and the depraved action is fre- 
quently diminished, sometimes wholly removed, hy the use of gentle 
counter-irritants, tonics, shower-baths, &c. 

The first aeries of cases consists of those in wliich the injury fol- 
lowed exposure to cold air. 

Total deafness in both ears following exposure to cold by sleeping 
in the open air. — A farm-laborer, aged 28, was admitted under my 
care at the St. George's and St. James's Dispensary, in June, 1850, 
on account of complete deafness in both cars. Ue said that eighteen 
months previously, after sleeping in an open cart in which ho was 
riding in the winter, a usuitl practice with him, intense patn came 
on between the right temple and ear, which was relieved by the use 
of veratrine ointment. About three weeks after the exposure to 
cold the deafness made its ajipearance, at first for a day or two 
only, and then disappeared : in the course of a few days, however, 
it recurred with increasing intensity and once more disappeared. 
This recurrence and disappearance of the deafness ended after a few 
more days in total and permanent loss of hearing. At the present 
time he cannot hear a gun, even if fired close to the head. He 
complains of loud noises in the head, and of great heaviness and 
sleepiness. All kinds of empirical treatment had been tried on 
him ; oils of various kinds had been dropped into the ears, with 
brandy and salt, and then hot baked salt behind them ; every 
species of medicine had been given, and he had been cupped and 
blistered at the nape of the neck, but without producing any good 
effect. On examination, the upper part of each membrana tympani 
was found to be red, the lower part being concave and white ; air 
entered through the Eustachian tube and caused a loud cracking 
sound. Some relief to the head-aymptoms followed a discharge 
from each meatus, which was kept up by the application from time 
to time of the chloride of zinc. 

Deafness and singing in the ears following exposure to cold while 
skating. — J. V., Esq., aged 49, consulted me in March, 1852. His 
health was good, and his constitution strong. He stated that twelve 
or fourteen years previously, while skating on a bitterly cold day, a 
singing sound suddenly came on in the left ear, which has remained 
ever since; being at times very loud, and then much subdued. A 
few years after this exposure, the left ear became gradually dull of 



376 THE DISEASES OF THE EAR. 

hearing, and recently both the singing and dulness of hearing have in- 
creased. The power of hearing varies, but is not worse aft^r fatigue 
or excitement. With the right ear the hearing distance was three 
inches ; with the left, half an inch only. Two leeches were ordered 
to be applied below each ear, and the ears to be syringed with warm 
water, the object being to remove congestion. This treatment was 
followed by relief; but with the further progress of the case I am 
unacquainted. 

Two other cases of injury produced by the application of cold air 
to the ear may be briefly alluded to. The first was that of a gentle- 
man, aged 21, who ten months before my seeing him, being exposed 
to a very cold February wind blowing in the left ear, had a singing 
and pulsation ensue within that organ ; these sensations are unaccom- 
panied with deafness, and are worse while in bed or reading. At 
times they wholly disappear. The second case is that of a clergy- 
man, aged 66, who having been exposed to cold in a railway car- 
riage, three years before my seeing him, was subsequently attacked 
by a whizzing sound in the left ear, which has never ceased. By 
sitting up late at night, or by entering a warm room from the cold 
air, the sound is increased, but is better rather than worse after 
dinner. Complains of dulness of hearing, as general conversation 
is not heard. 

The following are cases where the application of cold water re- 
sulted in injury to the ear : — 

Deafness following hathing in cold water, — T. F., aged 19, saw 
me on account of his deafness. He said, that more than a year pre- 
viously deafness came on slowly, after bathing daily in cold fresh 
water, and in a month or six weeks he became as deaf as at present. 
The afiection has been stationary for some months. He requires 
speaking to loudly [^within the distance of a yard, and at times suffers 
from a buzzing in the ears. He is not deafer during a cold, and 
does not hear better in a carriage. The right ear is rather worse 
than the left. The previous treatment consisted in dropping oils 
into the ears, and in syringing them with warm water. In each ear 
the watch was heard only when in contact. The membrana tympani 
appeared to be slightly more concave than natural, and its surface 
was dull and congested. The treatment consisted in the application 
of a vesicating paper behind each ear, and in taking small doses of 
blue-pill and iodide of potassium, a treatment which was followed bv 
a slight amelioration of the symptoms. 



NERVOUS DEAFNESS. 



377 



Benfneaa produced in two days by dipping the head in cold water. 
— A girl, aged 14, the daughter of a farmer consulted mc in 1853. 
She stated, that two years previously, when very much heated, she 
plunged her head into cold water, and two daya afterwards became 
so deaf that she refjuired to he loudly spoken to close to the head. 
The deafness varies slightly, being worse during a cold, and at times, 
from no assignable cause, better. The treatment consisted in keep- 
ing up a slight discharge from the surface of each mastoid process, 
and in giving small doses of the bichloride of mercury (one-thirtieth 
of a grain) with gentian, daily. The treatment, pursued during two 
months, resulted in decided improvement. 

Deafneaa and noises in the ears after bathing. — A man, aged 29, 
was admitted under my care at St. Mary'a Hospital, in July, 1858. 
He said, that six years before, after bathing in a canal of cold freah 
water, he became rapidly deaf in both ears, and in the course of a 
week was so deaf as to require to be distinctly spoken to quite close 
to him ; complained from the first of buzzing noises and pulsations. 
The deafness and the noises increase in damp weather, or when he ifl 
tired ; and he also hears worse in a carnage and amid loud sounds. 
The treatment consisted in the application of gentle counter-irritants 
over each mastoid process, and in taking alteratives, but without any 
beneficial effect. 



(■3.) Bcafness produced by the action of morbid poisons on the 
nervoua apparatue of the ear. 

As has been stated, in addition to the causes just detailed, the 
nervous apparatus of the ear often suffers from the action of the 
poisons of gout, typhus fever, scarlatina, measles, or mumps. Though 
unable to furnish any information of the modus operandi of the 
several poisons enumerated, in some cases where the functions of the 
organ have been wholly destroyed, the nervous apparatus of tlie ear, 
on dissection, has been found by me completely disorganized, and 
the fluid in the cochlea and vestibule dark-colored, and occasionally 
tinged with blood. Many of the cases of acquired dcaf-dumhnese 
originate in the effect of poisons of various kinds. A careful con- 
sideration of the symptoms attendant upon these cases, and the re- 
sults of treatment, indicate that whatever may be the immediate 
effect of the poison on the nervous tissue, the secondary effect is to 
produce congestion of that tissue. 



378 



THE DISEASES OF THE EAR. 



Noises and deafness after rheumatic fever. — Miss. B., aged S6, 
conEulted me in 1851. She stated, that ten years previouely she 
had an attack of rheumatic fever, which was followed by dulness of 
hearing in the right ear, and accompanied bjr a coontant whisxing 
sound and a pulsation which extended over the head. The left ear 
has lately become dull. The watch was heard only when pressed 
upon the right ear, or at a distance of six inches from the left. 
Neither ear presented any appearance of disease, except a slight 
dulnees of the surface of the left membrana tympani. The treat- 
ment consisted in applying mustard plasters and stimulating lini- 
ments to the nape of the neck, and the ctherial solution of cantha- 
rides behind the ears. The result of two mouths' pcrseveriince was 
such an improvement of the hearing power, that conversation could 
be more distinctly perceived, and the watch could be heard at half 
an inch from the right ear. 

Total deafness following an attack of rheumatic fever. — Mr. M. 
G., aged 17, a year and a quarter before consulting m^, had a had 
attack of rheumatic fever, which was followed by noises in both ears 
and gradually increasing deafness, so that in a month after the fever 
he could not hear any sounds. Since the attack, has now an*I then 
heard loud sounds for a very short time : but when lie saw me he 
was BO deaf that he could not hear anything, even when the poker 
and tongs were knocked againwt each other. The ears had been 
syringed, blistered, and galvanized without any efiect. There WM 
no appearance of disease in either ear. The case was at once re-> 
garde d by me as incurable. 

Partial deafness following aii attack of typhus fever. — ^Miss A. 
M,, aged 16, saw me on March 1st, 1851. Eleven years previouslj 
she had an attack of typhus fever, and during the illness became so 
deaf as not to be able to hear the human voice. After the symp- 
toms of fever had disappeared, the power of hearing slowly returned, 
until she was able to hear when loudly spoken to close to the head. 
There was no appearance of disease in either ear. 

Partial deafness following feeer. — P. A., Esq., aged 49, consulted 
me in December, 1853. Twenty years before, he had an attack of 
fever, during and for some time after which he was so deaf as to 
require to be spoken to close to the ear. The hearing gradually 
returned, and at the end of two years he heard perfectly well for a 
very short time, when the deafness as gradually returning, he soon 
had to he loudly spoken to within a yard of the bead. Does not 




NEHV0U3 DEAFNESS. 



now complain of noises, but has had a, ticking sound in the oars. 
The deafness is worse after flurry, excitement, or fatigue, after 
dinner, wine or beer ; a single glass of either of the latter increases 
the deafness instantaneously. Is better after a discharge from the 
nose, and while riding in a carriage. The hearing power of the left 
ear is gone. On examination, no unnatural appearance was detected 
in either ear, and the watch was heard when pressed upon the right 



Total deafneeg following an attack of fei'er.—Mias C. J., aged 
21, when a child had an attack of fever, since which time she has 
gradually become deaf, and at the present moment cannot hear 
even a loud clapping of the hands. Five years ago both tonsils 
were partially removed, and their remnants have recently been 
snipped, with no effect except that of producing great mental de- 
pression. There was no appearance of disease in any part of the 
organ. 

The poison of scarlet fever, like that of ti/phus, sometimes injures 
the nervous apparatus of the ear, and not unfrequently complete 
deafness is the result. The following are illustrative cases. 

Dulness of hearinff following an attack of scarlet fever. — Mrs. S., 
aged 26, had an attack of scarlet fever, eight years previous to 
consulting me, and since that time has been troubled with a dul- 
ness of hearing, especially during a cold. A year ago, after having 
suffered much trouble, and after being in weakly health, the power of 
hearing gradually decreased, and this decline was accompanied for 
the first time by pain, with irritation and discharge in both ears, 
together with constant noises like the blowing of bellows. Is un- 
able to hear general conversation, but a single voice is heard dis- 
tinctly. The left ear is worse than the right. On examination of 
the right ear, the surface of the meatus was found to he dry and to 
contain small portions of epidermis ; the membrana tympani was 
opaque, and the Eustachian tube pervious. The left ear was in a 
similar condition. 

Complete deafness in the right ear produced hy the poison of 
scarlet fever. — Mr. H., aged 20, had an attack of scarlet fever at 
four years of age, since which time the right ear has been so deaf 
as not to be able to hear even tlie slightest sound. On examina- 
tion, the right membrana tympani was observed to be more opaque 
than natural, and the left ear was perfect in every respect. 

—The peculiar poiaon which causes the disease generally 



880 THE DISEASES OF THE EAR. 

known by the name of mumps is very often the source of complete 
deafness, which, however, usually occurs in one ear only. In these 
cases, the nervous apparatus is evidently affected, as the deafness 
comes on suddenly, is usually complete, and, as a general rale, no 
appearance of disease can be detected in the meatus, membrana 
tympani, or tympanic cavity. When the nerve is not wholly para- 
lyzed, and some, although it may be a very slight degree of, hear- 
ing remains, the only plan of treatment which can be recommended, 
is the use of gentle counter-irritation over and around the ears, at 
the same time that the ear is exercised by means of the elastic speak- 
ing-tube. 

The circulation of bile mixed with the blood is sometimes a cause 
of deafness, and it is also well known that large doses of quinine 
are also liable to be followed by temporary deafness. I have met 
with only one case in which permanent injury to the ear was 
assigned to the use of large doses of quinine. 

The poison of gout may also give rise to deafness and other pecu- 
liar symptoms in the head. In two cases of this affection which 
came under my notice, it is interesting to observe that the head- 
symptom complained of, viz., a feeling of vacancy, was at once 
relieved by pressure upon the air contained in the external meatus. 

Distressing sensations produced in the ears hy gout, — D. T., Esq., 
aged 54, consulted me in June, 1857. He said that for the last 
four or five years he had been subject to attacks of gout, which had 
at times caused him great inconvenience, and the disease had recently 
made so much progress as to make him fearful that his brain was 
weakened by its influence. He added that he was never really clear- 
headed, excepting just after an attack of gout, when he supposed 
his blood was temporarily freed from the poison. He had rapidly 
aged in the course of the previous two years. An extremely dis- 
tressing symptom had lately presented itself in the form of a pecu- 
liar sensation of vacancy in the ears, accompanied sometimes by a 
low humming sound. There was no deafness, and the patient 
applied to me only on account of the sensations in the ear. On 
examination, small deposits of gouty matter were observed in the 
substance of the right upper eyelid ; the surface of the meatus ex- 
ternus was of a bright red color ; the circumference of the mem- 
brana tympani and of the long process of the malleus were also red; 
while the surface of the tympanic membrane was very bright. Air 
passed freely, and with the natural sound, into the tympanic cavity. 



NBBVOUS DEAFXESP. 



381 



The hearing power was pDrfect. By what, therefore, could the dis- 
tressing Bjmptoms be caused ? Were they the result of congestion 
of the nerve ? — a condition which, it seemed to mc probable, might 
render the nerve so exquisitely sensitive, thut the ordinary sounds 
eycr floating in the air might become a source of excitement to the 
ear. Being aware also, from pre%nous experience in similar eases, 
that pressure upon the external meatus so as to shut out or diminish 
the sound in the meatus would remove the symptom complained of, 
I closed with my fingers each external meatus, and the unpleasant 
symptoms at once disappeared. On subsequently exerting a gentle 
pressure on the ears hy the introduction of cotton steeped in water 
into each, the patient was enabled to leave in comparative comfort. 
For the purpose of preventing the recurrence of the symptoms, it 
was of course requisite to diminish the congestion, for which pur- 
pose two leeches were applied below each car, small doses of colchi- 
cum administered, and strict attention to diet enjoined. The quan- 
tity of wine was decreased from four to two glasses daily, and in 
lieu of beef and mutton, of which he tad been in the habit of partak- 
ing very abundantly, he was ordered to live principally on poultry, 
game, and fish, with abundance of farinaceous food and vegetables, 
The result of this treatment was the removal of the distressing 
symptoms in the ears, and the gradual disappearance of the attacks 
of gout. 



{b.) DISEASES IN WHICn THE BRAIN AS WELL i 
APPEARS TO BE AFFECTED. 



(1.) Hebiliti/ of the nervous apparatus arisiny from mental 
excitement. 
A young lady, of about 25 years of age, ia brought to mc by her 
mother, on account of deafness in both ears, one being much deafer 
than the other. The patient is pale, rather thin, and has a took of 
depression. She complains of humming noises in both ears, and 
hears better in a carriage. Upon examination her pulse is feebler 
than natural, and the deafness is so considerable that she requires 
to be loudly spoken to within a yard of her ears. There is no mor- 
bid appearance in any part of the ear, and the Eustachian tube is 
in a natural state. On inquiring as to the origin of the deafness, 
the parent states that they had not been able to detect any cause. 



SEti OF THE EAR. 



The deafness came on three jcars previously, when the young 
was in good health, and gradually increased, till in four months the 
patient had become as deaf as now. She is rather deafer aft«ir ex- 
citement and during fatigue. There is no hereditary tendency ta 
deafness. The young lady has remained at home with her mutber, 
has taken plenty of exercise in the open air daily, and retired to 
bed early ; but, for some reason or other, her nervous syatei 
not strong, and she was easily excited. On further queationing 
it is found, that about the period when the deafness came on, the 
patient was particularly nervous, and ultimately it turns out, by her 
confession, that she had been deeply grieved by the couduct of 
of her friends, and had often lain awake at night indulging in soi^ 
row, and that, at such periods, the noises came on in increase^: 
force. 

Another young lady, aged 19, is brought just after leaving scboolf 
where she was well taken care of, and so liked by all, that she cm 
preferred school to home. Her parents stated that six monlhs 
before, without any apparent cause, their daughter had grown gr»- 
dually deaf, and can at present hear only when very distinctly spokes 
to, ivitiiin a distance of two or three yards. The deafness ia worse 
during excitement. There is do appearance of disease in the ears, 
and the girl ia strong, active, and healthy ; her nervoun system tB, 
however, very sensitive, her feelings most acute, and she broods ia 
silence over slight mental troubles which would pass unheeded by 
ordinary persona. Perhaps all attempts to find out the cause of the 
deafness are in vain ; and the parents go away with the assurance 
from the medical man, that at the time the deafness first appeared 
there must have been some cause of mental excitement to call it 
forth. After the lapse of a shorter or longer period, the medical 
man learns, perhaps, that at the time in question the young lady at 
school suffered a great deal of mental anxiety, owing to her rdt- 
gioua views being in an unsettled state. 

These two cases are good types of the class of nervous deafness 
now under consideration. The causes may be very numerous, and 
in some instances are but slight, compared with the distressing 
symptoms which ensue ; but it must he borne in mind that, aa ft 
general rule, the nervous system has, from a variety of causes, been 
allowed to sink into a weakened condition. Thus the child may have 
been overworked, have suffered from indigestion, had too little exer- 
cise or not enough sleep ; ventilation also may have been defective. 




NERVOUS DE 



In a depressed slate of health from any of these causes, an appa- 
rently slight additional cause may produce the injurious effect on 
the nervoua system which has been indicated Sometimes there is 
no diminution of the hearing power, and the patients complain not 
of deafness, but rather of singing noises, which are increased by 
any mental excitement. In some cases the noises are not constant, 
but only appear after mental emotion ; the slightest unpleasant 
thoughts are sometimes suiBcient at once to induce the noises. 

The deafness and noises in this class of coses, if alight, can be 
cured by removing the cause (a depressed state of health), and by 
giving tone to the nervous system by tonics and by local applica- 
tions to the ear. In some cases, however, of this species of nervous 
deafness, the symptoms of noises become so greatly aggravated, 
that unless their peculiar character had been detailed by several 
patients, it would be difficult to creilit their existence. They may 
commence with a gentle singing, then increase to a hissing or wii- 
zing sound, that ituddenly changes to a series of sharp eraeks, like 
pistol-shots, followed by a rushing sound like the wind, or the escape 
of steam from a boiler, after which a rolling may ensue like thunder. 
These sounds vary much in intensity, being increased in some by 
rainy weather, in others by an easterly wind ; bodily fatigue may 
sometimes cause them to bo magnified, but the source of increase is 
usually some discomfort or excitement of mind. A young la<!y, for 
instance, comes into my room with her mother to consult me, and 
she says that the noises became rather worse than usual when told 
that she was going to see a medical man ; that they were accelerated 
when entering my house and waiting in the dining-room ; and that 
they reached their acme of intensity after the excitement attendant 
upon my examination of the ears, and questioning her about the 
symptoms. The important problem for consideration is, can the 
ears be improved ? So far as my present experience extends, I may 
say that a large number of the worst cases can he but slightly in- 
fluenced by treatment ; but there is still a large number which may 
be very greatly benefited by measures calculated to brace the nerv- 
ous system; as tonics, fresh air, exercise, and mental repose. In 
these cases I am giving electricity a, trial. 

Debility of the nervous apparatus of the ear, produced by over- 
itudy. — Lady D, brought her child to me in June, 1852. The young 
lady was twelve years of age, thin, rather tall of her age, and pale. 
The pulse was weak ; the tonsils large and red ; the mucous mem- 



384 THE DISEASES OF THE EAB. 

brane of the fauces red, thick, and rugous. The sub^maxillary 
glands were somewhat enlarged, and she had been subject to glandu- 
lar swellings in the neck. The appetite was good, and she partook 
freely of meat twice daily. She was taught at home with her sister 
by two governesses, one being for languages. She deroted between 
eight and nine hours daily to her studies. The history given me 
was, that during the last two years, without any assignable cause 
the power of hearing had gradually diminished, and there had been 
slight noises in the ears at times. On inquiry, it was elicited that 
she was greatly interested in her studies, and very anxious to make 
progress in them, never much tiring of her lessons. Her interest 
in them increased to excitement, and she was often agitated and 
distressed at not being able to accomplish as much as she desired. 
On examining the ears, a slight dulness was observable in each 
mcmbrana tympani ; the Eustachian tubes were pervious, but the 
hearing power was so diminished, that she required to be loudlv 
spoken to within a yard of the head. 

This deafness was at times so greatly aggravated, that consider- 
able difficulty was experienced in making the patient hear at all. 
It was, therefore, palpable that there was considerable debility of 
the nervous apparatus of each ear, for which tonics were prescribed 
also a gently-stimulating embrocation ; fewer hours were to be de- 
voted to study, and light nutritious food, as game, poultry fish 
was to be taken instead of so much meat. All this resulted in 
some slight amelioration ; but still the deafness was very con- 
siderable, and increased greatly at times. Under the circum- 
stances, another consultation took place, at which I clearly traced 
the attacks of increased deafness to more than usual nervous ex- 
citement following more than usual mental work. In addition to 
the previous tonic measures, entire rest from study in any shape 
was enjoined for three months, during the whole of which time the 
hearing gradually improved, and at the end of six months the 
patient was declared to be perfectly well ; and, although she has 
resumed her previous plans of study, moderated according to 
circumstances, the case remains satisfactory. 

To the above case the details of several others might be added 
were not a brief allusion sufficient. Thus a lady, ageil 27, consults 
me for deafness accompanied by noises which graduallv came on 
during the previous four years. The nervous system never was 
strong, but underwent a severe shock, about the commencement of 



NERVOUS DBAFNE88. ^8& 

the period mentioned, from the breaking off of a matrimonial en- 
gagement. With the continuance of tho mental sorrow the deaf- 
ness and noisca had gradually increased, and were always accelerated 
after much mental dejection. 

Another lady of nervous temperament and warm feelings, was 
sitting at home awaiting the return of a brother to whom she was 
greatly attached, when he was brought home dead from a fall in 
tho street. For the space of a year the sister gave way to despon- 
dency, and, as she told me, the thought of her brother during the 
whole year was scarcely a moment absent from her mind. At the 
end of that time, as her spirits began to improve, noises appeared 
in the ears and head, dulness of hearing followed, and both noises 
and deafness so greatly increased, that in the course of another 
year, when seen by me, she was so hard of hearing as to require to 
be loudly addi^ssed at the distance of a yard or two, while the 
noises had reached a pitch of extraordinary excitement. There 
TTas scarcely any conceivable sound, whether of thunder, cannon, 
firing guns, bells, hissing, rolling of the sea against the beach in a 
storm, or winds howling, to which this lady was not subject. These 
sounds intermixed and alternated in a manner quite indescribable. 
They remained of the same general intensity, varying somewhat 
according to the weather, for several years ; when another severe 
domestic bereavement occurred, followed by some new noises of a 
still more intense character, but her deafness remained much the 
sane. 

Another lady, who married at about 26 years of age, was sub- 
jected to severe domestic trials, which, after preying upon her mind 
for some years, ended in such total deafness, that she could not hear 
a pistol-shot fired close to her head. 

The variable amount of deafness iu this class of cases is sometimes 
very marked. Thus, I had for a long while a patient under my care 
who, when perfectly tranquil, could distinctly hear his daughter 
reading to him at about the distance of a yard ; but if his daughter 
told him anything which excited his interest, he became so thoroughly 
deaf as not to ha able to hear a sound, and would remain so until the 
excitement vanished, when his hearing would return. 



3& 



THE DISEASES OF THE EAR. 



(2.) Debility of the nervous apparatus of the 
general bodily debility. 



r produced by 



It is difficult to draw a correct comparison between the i 
of cases of deafness dependent upon excess of mental excitement, 
and those arising from overtasking the body ; but from the dat». 
before me, perhaps those of the class now to be considered i 
the most common. They occur in both sexes, but are more fi». 
quently met with in the female; and present great variety of fors 
as well as cause. Sometimes tliey are temporary, and produced h 
a long walk, heated rooms, late hours, &c., when noises, with d 
minished hearing power, come on, but disappear after rest. Oth«i 
cases, and even some of those which come on suddenly, may, hoir- 
ever, remain more or less permanent. Thus, cases have been i 
with in my experience, in which patients have become totally deai 
after the administration of too violent a purgative, or after an atta< 
of diarrhoea or cholera, and after the nervous exhaustion attcndanl 
upon childbirth ; in some instances of the latter, the deafness haa 
begun with the birth of the first child, and increased with i 
successive birth, until at last the nervous power was wholly lost. 
Perhaps the most common cause of nervous deafness from phTsicftl 
debility is the want of proper care in the management of young' 
persons, and particularly girls, when they are growing fast. la 
hospital practice, young nursemaids who carry heavy children, and 
whose night's rest is often disturbed, and youths just enterinf 
laborious situations, are found to suffer. Any cause, in fact, which 
reduces the nervous energy of the body to a state too low for tfae 
due regulation of the functions of the various organs of the fram^ 
may he followed by a manifest depression of the nervous power of 
the ears, which shows itself not merely in diminished power of heaiv 
ing, but often by singing and other sensations in the ear, and somo- 
times by severe pain, like tic doloureux. In eases where debility of 
the nervous system of the ear is the result of a debilitated state of 
the body, the pulse, as a general rule, is weak, and there are symp- 
toms of previous or present indigestion. Generally, no uuhealth* 
condition of the organ itself is apparent ; though, in recent casea, 
the cerumen may be softer and more abundant than usual, and i 
old standing cases may even be absent. 

The treatment of cases of debility of the nervous apparatus of th« 




NEKVOUS DEAFSESS. 



ear arising from bodily debility. consiBts in imparting, by every 
possible means, strength to (he general system. Exercise in the 
open air. a due amount nf rest and sleep, we 11- ventilated rooms by 
day and night, abundance of nutritious food, stimulants in modera- 
tion, tonics in the shape of quinine, bark, strychnine, creasote, &c., 
should be prescribed; while locally, gentle stimulants should be 
applied over and around the ear. I have never found the vapor 
of ether applied to the tympanic cavity by means of the Eustachian 
catheter of any service ; nor has my limited experience of the use 
of galvanism and electricity hitherto been favorable to their em- 
ployment. Some cases are decidedly amenable to treatment, and 
the noises diminish or disappear, while the deafness is greatly 
diminished; but if the cause in which the deafness originated be 
allowed to continue, or if any debilitating influence be present, total 
deafness may ensue in spite of every remedial effort. The following 
cases arc ail interesting. 

Deafness produced by want of sufficient sleep ; cure. — In the early 
part of 1855, a young gentleman, aged 14, was brought to me by 
his father, on account of gradually increasing deafness. He ap- 
peared to be in tolerable health, and was at school in the neigiibor- 
hood of London. No cause could be assigned for the affection, which 
had 60 far advanced as to cause bim great discomfort from his ina- 
bility to hear what his masters said to him. On examination, it 
became apparent that the deafness depended upon debility of the 
nervous system, for there was no history of any other disease, nor 
was there any appearance indicative of disease. The patient had, 
however, occasional noises in the ears, following over-exertion, and 
he certainly was deafer when he was tired. On inquiry, I could 
discover no special cause for the deafness, as he followed the same 
rules and regulations which were pursued by all the hoys in the 
school. I prescribed internally quinine, and a stimulating liniment 
externally, giving directions that he should not be over-worked. 
In a month's time the boy was seen again, but remained in much 
the same state, so I requested to be allowed to see the lady with 
whom he boarded, in order to ascertain further particulars as to his 
mode of living. On the most minute questioning no sufficient cause 
could be detected, except that, being very desirous to prepare his 
lessons well, he sat up so late that when the time arrived for getting 
up, he was so sleepy as to be roused with difficulty. It was at once 
rendered probable, that the debility of the nervous apparatus of the 



THE DISEASES OF THE EAB. 



ear might be dependent upon the want of sleep ; and I therefore 
requested hia friends to see that his duties were so relaxed thai he 
could take as much steep aa he required, and gave directions that 
he should go to bed at eight o'clock, and sleep until he awoke of bla 
own accord. The result was, that for several successive ntghtfi, he 
slept for fourteen hours, and bj degrees the number was reduced to 
ten, which was his usual allowance for three weeks, at the end of 
which time he returned to me, when, to tho gratification of all, it 
was found that his hearing was nearly restored, and he was no longer 
styled " the deaf boy" at school. This patient has been seou by me 
twice or thrice since, at considerable intervals, in consequence of 
the deafness returning ; but each time it was evident that the ncr- 
TOttB system bad been too much exhausted, and the administration 
of quinine, with less work, and an increase in the amount of sleep, 
soon restored the hearing. 

Total detrffifgg produced by the nert<oug shock consequetU vpon 
successive accoitchemcnts. — Mrs. B., aged 40, pale, and of a nenroDA 
temperament, consulted me in 1850, on account of complete dcaf- 
ness in both ears. She stated that she had married in India ten 
years previously, and at the time of her marriage she could hear 
perfectly well. On the occasion of her first confinement, previous 
to which her hearing was still perfect, she suffered a good deal from 
exhaustion, and this was followed by a great degree of deafness, sa 
that she could scarcely bear what was said to licr, even when the 
voice was much raised. Upon getting up, and growing stronger, 
the deafness was so much relieved that she merely required to b« 
spoken to a little louder than usual. During each successive con- 
finement in India, amounting in all to four, the deafness greatly in- 
creased, and after each recovery became more permanent, until, on 
the last occasion, she remained as deaf as at present, whon she is 
obliged to have recourse to signs. Indeed, she has never heard the 
voices of her younger children, and can only by the movementa of 
their lips understand their words. 

Dehilittf of the nervous apparatus of the ear arising from over- 
exhaustion in Ijidia. — Captain T,, aged 40, came home from India 
in 1858, having undergone great fatigue, and his health having been 
greatly shattered, while his hearing power had so much diminished, 
that when he consulted me I was obliged to speak very distinctly 
within a yard of liis head. He complained of constant loud singing 
in the ears, which was increased by the slightest exertion. On ex- 



NERVOnS DEAFNESS. 



amining the cars, no aheration from tLe Dormal condition could be 
detected, and the Eustachian tubes were in u natural state. The 
treatment consisted in sending the patient to the seaside and in 
giving him quinine, using at the same time a stimulating liniment 
oyer the ears and at the back of the neck. In two months his 
strength had greatly increased, with a corresponding improvement 
in the hearing. He returned to the seaside to pursue the treatment 
in capital spirits, and was induced to go out un two consecutive days 
to evening parties, at which he stayed tOl very late. Nervous ex- 
haustion followed, and his hearing sank to the same low ebb as when 
he first consulted me : nor was it until after two months of very 
quiet life and steady keeping to the prescribed treatment, that he 
again began to improve. 

Ke.rvou» dfafju'gs produced by over-exertion. — E. Clarke, aged 31, 
a tall muscular carter, was admitted under my care at St. Mary's 
Hospital, on January 27th, 1859. He stated, that fourteen years 
before, when out of health, deafness came on in the left ear, accom- 
panied by noises, sometimes like a kettle singing, at others, like the 
ringing of bells. On recovering his health, he found himself per- 
fectly deaf in the left ear, which has remained so ever since. Eleven 
weeks ago, when a good deal exhausted by hard work, he took a bad 
cold, during which singing came on in the right ear, with loud noises, 
like the ringing of bells, and were accompanied with so serious an 
amount of deafness, that he required to be spoken to in a loud voice, 
within a yard of his head. The patient's pulse was weak, and he 
had a worn aspect, as from exhaustion of the nervous system. On 
examination, no appearance of disease was visible in either ear, and 
the Eustachian tubes were pervious. Two grains of quinine were 
ordered to be taken twice daily, and a stimulating liniment to be 
rubbed over the surface of the ears, at the back of the neck, and 
down the spine. In the course of a week the noises decreased 
greatly, and in a fortnight they had wholly disappeared, while the 
hearing power gradually increased ; so that when he left the hospi- 
tal, at the end of six weeks, to use his own words, he " at times 
hears quite nicely." 

Severalcaacaofaaimilar character might be cited, in which equally 
favorable results followed the administration of strychnine, in doses 
varying from one-thirtieth to one-twentieth of a grain, twice or thrice 
daily ; and in some instances, where neither quinine nor strychnine 



390 



THE DISEASES OF THE KAR. 



were of any benefit, doses of creaaote, or of morphia, or of hoUt to 
gethor, were productive of great improvenicnt. 

Nervous (hafnesf relieved by creasotc and morphia. — Miss M. 
aged 29, in good health, but very easily excited, consulted me ia' 
January, 1859, on account of deafness. Four years pceviously her 
left ear gradually became deaf, accompanied witli noisea very diffi- 
cult to describe, but Bomething like a whizzing, and these nois«e 
were increased by any external noiae, or if she felt nervous, tired, 
or excited, and were worse at night. In a few months the ngbt 
ear was also affected in the same way. In both the deafness waa 
gradually jncreasiog. This deafness was also accompanied by a 
sudden loss of voice after she had spoken a few words. The only 
cause to which she can ascribe the deafness was the habit of going 
for many hours without food, and then eating very rapidly. She 
had been treated by blisters, whose use had been followed by a rapid 
advance of the deafness, and she had been told tbat her case was in- 
curahle. At the time of her first consulting me, it was requisite to 
speak loud within a yard of Ler head, and she was deaf to all gene- 
ra! conversation. On examination, each membrana tympani had ft 
perfectly natural appearance, and the Eustachian tubes were healthy. 
The treatment consisted in using gentle counter-irritation over ea^ 
ear, the back of the neck, and down the spine, and in adminiBteriaff 
creasote and morphia, in doses of two or three minims of the former 
to one-twelfth of a grain of the latter, twice daily. This treatment 
was continued perscvoringly for four months, at the same time that 
every measure for restoring the general health as respects food, ex- 
ercise, and diet, were resorted to, and at the end of the treatment 
the hearing power was so greatly improved tbat she could both hear 
and take part in general conversation. 

Cases of nervous affection of the ear sometimes occnr in which th«, 
chief symptom is pain ; the treatment does not differ from that of 
the last class of cases. 

Pain in the left ear, accovipanied hy diminished power of hearing, 
following over-fatigue. — Miss T., aged 25, pale and not strong, wM 
brought to consult me, in May, 1856, on account of a pain in the 
left ear ; this pain had made its first appearance about a year before 
after the patient had undergone considerable fatigue by attending 
several evening parties in succession, and remaining very late; and 
the pain was much accelerated by any cauae which produced fatiinie. 
The hearing power was very slightly affected ; and as the other ear 



k 




NERVOUS DBAFKBSS. 391 

was perfect, no complaint was made respecting the hearing. On 
examination, the organ appeared to be quite healthy ; and feeling 
that the pain arose from deranged action of the nerve consequent 
upon debility, quinine was prescribed internally, and mild stimulants 
applied over the ear and down the spine. This treatment was fol- 
lowed by considerable success, as the pain disappeared in the course 
of a month, but returned slightly upon the patient having to undergo 
great fatigue. 




CHAPTER XVI. 

THE DISEASES OF THE NERVOUS APPARiTUS (cone/tM 



In the coses hitherto described of disease extending from the tym- 
panic cavity to the brain, the uppor osseous wall of the tympanmn 
was the part affected, and the medium through which dise&se ad- 
vanced to the middle cerebral cavity. There is, however, anotber 
medium by which disease may be conveyed from the tympaoic cavity 
to the brain ; and that is through the labyrinth. When it is 
membered that at the inner wall of the tympanum a delicate m 
branc (mcmbrana fenestrae rotundie) is all that separates it from the 
cochlea, and that the base of the stapes with its fine ligaments form 
the only septum between that wall and the vestibule, it will nsto- 
rally be inferred that disease in the tympanic cavity would fre- 
quently advance to the labyrinth. The occurrence is, howerer, in 
fact, very rare, for tbis reason, that ulceration of the mucous mem- 
brane of the tympanum ia far from a common disease, while, under. 
the influence of chronic inflammation and of the secretion collected 
ID the tympanum, the membranes both of the fenestra rotunda i 
ovalis become thickened and turgid. 

I am not aware that any case has been recorded in which diseaae 
had made its way through the fenestra rotunda to the labyrinth 
but in the course of my dissections I have found the mediom oT 
communication to have been, in one instance, the fenestra oralis, 
and, in the other, a carious aperture in the outer arm of the ex- 
ternal semicircular canal, where it bulges into the tympanic cavity, 
and ia covered by the tympanic mucous membrane. When Buppa- 
ration takes place in the labyrinth, the disease readily adranoea 
through the cribriform floor of the meatus auditorius intemna to tbo 
auditory nerve, and thence to the base of the brain and medulla ob- 



NEKVOUS DEAFNESS. 39b 

lotigata. In certain cases purulent matter is effused beneath the 
arachnoid over the whole surface of the base of the brain, surround- 
ing the nerves in their cranial course ; and the substance of the pons 
Varolii or medulla oblongata may be destroyed by ulceration, or an 
abscess may form between the arachnoid and pia mater. In some 
oases the disease extends a considerable distance down the medulla 
spinalis. 

In some cases the labyrinth becomes carious or necrosed, and the 
dead bone is discharged without the production of any symptoms 
of cerebral disturbance, as in the following eases. The first oc- 
curred to my friend Mr. Hinton, who kindly placed the preparation 
in my museum. It was of a. man let, 55, who suffered from a dis- 
charge from the right ear for some years, and at last the cochlea 
was discharged entire. The second case occurred to Mr. Shaw, and 
the following report is extracted from the seventh volume of the 
Tranaactiong of the Pathological Soeteiy of London : — 



Extraction from the left ear of a hog of the greater part of ike petrosal 
portion of the temporal bone, inclvding the meatus auditorius in- 
temus and labyrinth, separated by necrosis. 



"A boy from the country, let. 7, was admitted into the Middlesex 
Hospital on the 31st of July, 1855, under Mr. Shaw, for otorrhcea 
aifecting both ears. The disease succeeded a severe attack of scar- 
let fever, which he had two years and a half ago. From the right 
ear the discharge of pus was not of great amount. The left ex- 
ternal ear projected considerably beyond its proper level, and an 
irregular piece of bone, surrounded with fungous granulations, pro- 
truded from the meatus into the concha. He had paralysis of the 
muscles of the left side of the face ; for a year he had been com- 
pletely deaf in both ears. 

" On the 3d of August, he was put under the influence of chlo- 
roform, when Mr. Shaw first extracted the piece of bone which 
projected into the concha ; this appeared to have been the posterior 
border of the external meatus of the temporal bone. 

" The cartilaginous tube having been ulcerated by the pressure of 
the loose fragment, the point of the little finger could now be passed 
inwards to some depth; when another larger piece of bone was felt 
rolling freely in the cavity. This was seised by the dressing 



394 



THE DISBABES OP THE EAB. 



forceps ; and after it had slipped onco or twice, owing to its hari 
ness and amoothness, it was extracted by employing force and ^ 
twisting motion, so as to favor its coming in a proper direction. Fw! 
a few seconds after the removal dark venous blood flowed ratho^ 
freely. As a precaution, he was kept in bed for a week ; by degre 
the discharge lessened, and ibe ulcer of the tube cicatrized. Hm 
outward symptoms arose ; and in the end of September, except f 
the paralysis of the face, the deafness, and a trifling discharge from 
both ears, he loft the hospital in good health." 

BeBcriptton of the Specimen. — The density of structure, vreight»i 
and shape of the portion of bone last removed, at once showed tha£ 
it formed nearly the whole of the petrous portion of the temporal 
bone. It was of irregular cylindrical, or rhoraboidal figure ; it mea- 
sured one inch in length; its average thickness id various directions 
was half an inch ; it weighed twenty-two grains. On one side, 
nearly in its centre, was an opening and cavity with well-defined 
borders and walls, which was recognized to be the meatus audito- 
rius internus. The depth of the meatus, from the margin to the 
thin perforated plate through which the auditory nerve penetrates 
into the labyrinth, was three-fifths of an inch ; and, as that is the 
full depth of the cavity in its normal state, it was thereby fihowa 
that the whole of the internal meatus waa included in the specimen. 
At the bottom of the meatus could be seen the commencement of 
the canal for the portio dura. On the side of the specimen in rela- 
tion with the brain, the surface presented the cancellated appearand 
peculiar to the diplbe ; whence it was concluded that, in the detach- 
ing of the necrosed part, the process of separation had taken plac« 
in the diploe — that the cortical layer bad retained its vitality, and, 
remaining in contact with tlie dura mater, had served as a barrier to 
prevent disease from extending to the cerebrum. On turning ths 
bone around to view it in its opposite aspect, the side then exposed 
was seen to be the internal wall or boundary of the tympanic cavity; 
it was easy to distinguish the "promontory," having above it lh« 
'* fenestra ovalis," and below it the "fenestra rotunda;" the two 
latter openings were broken and irregular, and through the enlaj-gad 
holes thus produced the interior of the "vestibule," with its fosse, 
the cochlea, modiolus, and lamina spiralis, somewhat injured, wer4 
seen. At the posterior part of the specimen portions of the senit 
circular canals, broken off near their junction with the veatibnle^ 
stood up distinctly into view. 



NERVODS DKAFNBSS. 



In other instatces, although the brain is seriouBly implicateil. the 
patients recover, as in the following case quoted from Mr. Wilde. 
He saja : "I am indebted to Sir Philip Crampton for an examina- 
tion of one of the most extraodinary pathological dissections of 
diseased bones perhaps in existence, consisting of the entire in- 
ternal ear, cochlea, vestibulum, and Bemicircular canals, with a 
small portion of the inner wall of the tympanum, which he drew 
forth from the meatus of a young lady who, after the most iirgent 
symptoms of inflammation of the brain, with paralysis of the face, 
arm, and leg, and total, deafness of one side, recovered from the bad 
symptoms and the paralysis of the extremities after a copious dis- 
charge from the ear. This discliarge, the paralysis of the face, and 
deafness, continued some time, accompanied by occasional attacks 
of pain in the ear, till one day Sir Philip, perceiving a portion of 
loose bone lying deep in the cavity of the meatus, drew forth the 
specimen from which the illustration in the volume was made. It 
does not appear that the hard external enamel of the bone was 
affected, but the scala cochleae is far more beautifully displayed 
than could possibly have been done by art." 

In the following case, which, on several grounds, is one of great 
interest, the disease advanced through a carious orifice in the semi- 
circular canal to the labyrinth. 

Digeate in the tympanic cavity, ezte-ndtng through a carious orifice 
in one of the semicircular canals to the labyrinth, and thence by the 
auditory and faeial nerves to the brain. — On the 28th of March, 
1851, I was called in by Mr. Such, of Dalby Terrace, City Road, at 
the request of Mr. Coulson, who had also seen the patient, to see a 
German gentleman, aged 26, the history of whose case I found to 
be as follows : — He was of a robust constitution, andhad generally 
enjoyed the best of health: indeed, even when first seen by me, he 
had the appearance of a stout, healthy man. Between four and 
five years previously, ho complained of occasional pain in the right 
ear, which was usually followed by a discharge that by degrees be- 
came constant. Three weeks before my seeing him, he suffered 
from a severe attack of pain in the head, which ceased on the 
occurrence of an increased quantity of discharge. Nothing par- 
ticular happened further until ten days previous to my visit (except- 
ing a sleepless state at night), when he was suddenly seized with a 
violent pain in the head, which the ordinary remedies failed to 
relieve ; and by degrees this pain extended to the back of the neck, 



896 THE DISEASES OF THE EAR. 

and as low as the sixth dorsal vertebra. About the same time 
there was paralysis of the right facial nerve. For several days 
there had been a continual shivering fit about two o'clock p.m. On 
the evening of the 28th, at which time I saw him, he was suffering 
from great pain at the back of the neck ; was very restless, par- 
ticularly at times, but talked quite sensibly ; the right facial nerve 
was paralyzed ; he squinted, and the pulse was 85. The external 
meatus was nearly filled by a polypus: the discharge was very 
fetid and abundant. A large blister was ordered to be applied to 
the nape of the neck ; the ear to be frequently syringed with hot 
water; and, as the patient Was very sensitive to the action of 
mercury, a quarter of a grain of gray powder, with three grains of 
extract of henbane, were administered every two hours. 

March 29th, 9 p.m. — The mercury has already caused great ten- 
derness of the gums. The symptoms have materially increased; 
the pain at the back of the head was very violent this morning, the 
squinting continues, and he sees double. At three o'clock to-day 
he became insensible, but was roused by a loud noise, and spoke 
rationally for a minute or two, but then relapsed into a state of 
incoherency. Pulse as yesterday ; respiration oppressed and low ; 
face and head congested and blue ; discharge from the ear abundant 
and fetid. Leeches were applied below the ear. 

March 30th. — Slight relief followed the application of the leeches, 
but the patient soon grew rapidly worse. The right side of the 
body became paralyzed, the breathing stertorous, and the face livid. 
Insensibility gradually came on, and he died at 6 p.m. 

Autopsy, twelve hours after death. — ^With the exception of a large 
quantity of chocolate-colored fluid in the lateral ventricles, the 
cerebrum was 4icalthy, as was also the cerebellum. The arachnoidal 
surface of the dura mater, covering the superior and mastoid sur- 
faces of the petrous bone, was in a healthy state ; but upon removing 
it from the bone, over two small portions of both surfaces, it was 
found to be softer than natural, and these soft portions covered 
apertures in the diseased bone. The appearance of disease was, 
however, so slight, that it was quite manifest that the affection of 
the ear had not made its way inwards at either of the two points. 
On removing the brain, there was evidence of very extensive disease 
at its base. Purulent matter was deposited beneath the arachnoid, 
from the roots of the olfactory bulbs, anteriorly, to the medulla ob- 
longata, posteriorly. In some parts this pus was of a dark color ; 



TJS DEAFNESS. 



397 



in otters, as in. tlie pons Varolii, the araclinoid membrane was 
ulcerated. The priacipal scat of the disease was the right side of 
the pons Varolii, the suhstance of which was ulcerated to the depth 
of n line to a line and a half, over a surface as large as a sixpence. 
All the nerves, at their origins, were surrounded with pus, and the 
substance of the facial and auditory nerves of the right aide was ao 
soft as to bo scarcely distinguishable from purulent matter. On 
examining the petrous bone, the dura mater around the orifice of the 
meatus auditorious internua was observed to be softened and de- 
tached from the denuded bone. The portions of the auditory and 
facial nerves within the meatus were also in a state of suppuration. 
The whole of the petrous bone being removed for the purpose of 
careful dissection, the following was the condition of the parts 
detected. The estemal meatus contained two polypi, one of which, 
as large as a small pea, was attached, by a broad base, to the poate- J 
rior wall of the meatus, about its middle ; the other, and smallOTjfl 
about the size of a grape seed, was also attached to the meatus near 
the former. When the membranous meatus was separated from the 
bone, there was found in the latter an orifice between two and three 
lines in diameter, so that a communication esisteti between the 
meatus and the mastoid cells ; there was, however, no orifice in the 
membranous meatus, and consequently the discharge from the ear 
came not from the mastoid cells, but from the surface of the meatus 
only. The membrana tympani was entire, but quite white and 
much thicker than natural. The tympanic cavity contained a large 
quantity of fetid pus, and its lining fibro-mucous membrane was 
ulcerated at several points. Within the cavity there were also two 
portions of carious bone, one projecting towards the cavity of the 
cerebrum and in contact with the outer surface of the dura mater; 
the other, looking towards the cavity of the cerebellum aod also in 
contact with the dura mater, which membrane, as before slated, 
was, at the points referred to, thick and soft. The ossicles were 
present, and the stapes adhered with its usual degree of firmness to 
the circumference of the fenestra ovalis. On laying open the cavity 
of the vestibule, it was found to be full of a dark-coloretl pus, having 
a fetid odor ; the semicircular canals were also full of similar mat- 
ter, anil the osseous wall of the superior canal was carious at two or 
three points. This purulent matter extended from the vestibule 
and cochlea to the meatus auditorious internus. While carefully 
examining the external semicircular canal, where it makes a bulging 



THE DISEASES OF THB EAK. 



in the tympanic cavity, a small carious aperture, not larger t3iKB» 
small pin's head, was detected in it, wbicli contained fetid pus, anil 
was the only medium through which diaease could have been traii»-_ 
mitted from the tympanic cavity to the vestihule. 




Cviea of the Extsrniil gcmiiiirculs: 
in tbe SemicirflalBr CiduE, showin 
Tjmpania Cavity ; the apper irutl 



I have described this case as one of dieease originating in t 
tympanic cavity, and extending thence to the vestibule, JQwart; 
and to the meatus, outwards. The grounds for my belief that 1 
disease originated in the tympanic cavity are various. In the f 
place, it is very rare for suppuration to originate iu the labyri 
nor do I recollect ever to have met with a well-marked case of t 
kind : and had it, in this instance, originated in the labyrinth, I 
would most probably have produced death before it reached th) 
tympanum. In the second place, the tympanum is, as has bet 
stated, a frotjucnt seat of disease ; and the presence of the i 
detached portions of necrosed bone indicates long-standing diaeaseui 

The nature and progress of the disease would appear to have 
the following : — When it first made its appearance, it was probabH 
one of catarrh of the mueous membrane ; the quautity of muoui 
secreted was too large to admit of its entire escape through thai 
Eustachian tube ; the membrana tympani was consequently pressed I 



NERVOUS DEAFNESS. 



upon, and, instead of ulcerating and allowing the matter to escape 
externally, became itself much thickened and very rigid ; the secre- 
tion being thuB confined in the tympanic cavity, produced caries of 
the bone and penetrated the labyrinth. There can, it seems to me, 
be no doubt, that had the niembrana tympani been partially de- 
stroyed, and free egress been in that way afforded to the secreted 
matter, the disease in the bone might Lave been prevented, and the 
life of the patient by that means saved. 

Another opportunity was kindly given to me, by the late Mr. 
Avery, of seeing the post-mortem, and making a cai-eful dissection 
of the ear, in a second case of disease advancing from the tympa- 
num to the labyrinth. In this instance, the medium of communica- 
tion was the fenestra ovalis, which had been left open after the 
removal of the stapes by ulceration. 

Ulceration of the tympanic mucout membrane; extension of dia- 
ease to the labyrinth throvgh the fenegtra ovalis. — James Warner 
Smith, aged 17, a sailor, was admitted into the Cliaring Cross Hos- 
pital, on the 14th of January, 1846. The history of bis case was, 
that at five years of age he had an attack of measlts, followed by 
an abundant discharge from the left ear, from which he has never 
since been perfectly free, although occasionally the quantity was 
very small. He had usually enjoyed good health. Three months 
previously, when off the Cape of Good Hope, he was np aloft during 
a gale, and lost his cap. Great pain in the car followed this acci- 
dent, and the quantity of discharge increased. There have been 
many attacks of pain since, and occasionally a sanguineous dis- 
charge. When ho came on shore, he took a fresh cold, and the 
pain in the head and ear became very violent. He now consulted 
a surgeon, who ordered him injections, drops, and ointments ; but 
not obtaining any relief, he applied to Charing Cross Hospital. At 
the time of his admission, he complained of constant pain in the left 
ear, and in the left side of the head as high as the vertex, with a 
certain degree of pain also on the right side. The muscles on the 
right side of the face were constantly twitching, and the mouth was 
fts constantly drawn to that side. Some intolerance of light was 
also observed. An abundant offensive discharge proceeded from 
the left ear ; but there was no tenderness over the mastoid process. 
January 16th. — Has had a violent paroxysm of pain in the night, 
bnt is better this morning, and the twitching has subsided, except 
in the right eyelid. Calomel and opium were administered. 



400 THE DISEASES OF THE EAR. 

January 22d. — Much better ; slept well ; pain abated. 

January 24th. — ^Pain returned as violently as ever. 

January 27th. — Delirious during the whole of the day. 

January 29th. — Delirium continues : complains of intense pain 
in both sides of the head ; discharge from the ear abundant ; head 
drawn backwards. 

January 30th. — The delirium has left him, but he is exceedingly 
drowsy, and is roused with great difficulty. The movements of 
the limbs and their sensation unaffected. The pupils acted pro- 
perly. 

February 1st. — The drowsiness has vanished ; has had no deli- 
rium ; and has passed a good night ; but still complains of consi- 
derable pain in the ear and over the eyes. He remained in this 
state until the 5th, when he gradually sank, without coma or 
cerebral symptoms of any marked character. The retraction of 
the head continued to the last. He was quite sensible before he 
died. 

Autopsi/f thirty-six hours after death, — On removing the dura 
mater, the surface of the arachnoid was observed to be remarkably 
dry ; the vessels of the pia mater were more than usually injected 
on the convex surface of the hemispheres ; there were two or three 
small yellow patches beneath the arachnoid. Each lateral ventricle 
contained at least three ounces of clear fluid ; in the posterior 
corner of the right, and in the inferior of the left, were two patches 
of bright yellow lymph, as large as half-a-crown, which were covered 
by a thick creamy purulent fluid. The third ventricle contained a 
dark clot of blood, of the size of a small walnut, which could be 
traced into the fourth ventricle, where there was also a small coafni- 
lum. The commissura mollis was broken down. Surrounding the 
lower part of the commissure of the optic nerves, and covering the 
pons Varolii, crura cerebri, medulla oblongata, and upper part of 
of the medulla spinalis, was a layer of pure yellow pus and lymph, 
nearly half an inch thick ; it embraced the nerves at the base of 
the brain to their passage through their several foramina. The 
parts in direct contact with this layer were very soft. Under the 
pia mater, where the right anterior lobe rests on the orbital plate 
of the frontal bone, there was a patch of effused blood, the size of a 
shilling. The dura mater covering each petrous bone was healthy, 
and the exterior of the bone did not present any appearance of dis- 
ease. On examining the cavity of the ear, the membrana tympaai 



NERVOUS DEAFNESS, 



401 



» 



yns fonnd to have been destroyed by ulceration, and all the ossicles 
had disappeared. The tympanic cavity was full of the most offen- 
sive secretion, and its lining membrane was ulcerated. The fenestra 
ovalis was opon, and, in the cavity of the vestibnle, similar matter 
was found to that in the tympiinutn. The whole of the natural 
membranous labyrinth had been destroyed. The auditory nerve 
was tumefied, and of a dull livid color, the disease having evidently 
advanced to it through the crihriform floor of the internal auditory 
meatus, and thence to the base of the braiu. 

It is to be remarked, that in this case there appeared to be no 
obstacle to the free egress of the matter, except the accumulation 
of thick masses of it in the cavity of the tympanum. It is far from 
improbable thai, in cases of ulceration of the mucous membrane of 
the tympanum and loss of the stapes, the thick secretion in the 
tympanum may he i{uite sufficient to cause the disease to advance 
inwards. The case is also another illustration of the necessity there 
exists for frequently washing out the tympanic cavity with warm 
water. It is, however, no doubt possible, ere the stapes is removed, 
for the disease to advance to the vestibule without the agency of the 
pent-up matter in the tympanum. 

Besides the two cases just described, I have met with two others ; 
and as these four cases are the only instances I have fonnd on re- 
cord of this peculiar form of the disease, brief particulars of the two 
latter are subjoined. 

The first of these cases occurred in the practice of Mr. Streeter, 
and was laid by him before the Westminster Medical Society on the 
13th January, 1844. 

Disease extending from the tt/mpanie cavity to the labyrinth, and 
thence to the medulla oblongata and the bate of the brain. — The 
patient was a lady, aged 42, who had been deaf in the right ear 
since the age of seven, hut from what cause was not known. Two 
or three months previous to her death, she became affected with a 
severe headache, for which a blister was applied at the back of the 
neck. Nothing serious, however, was thought of the matter until 
the 17th December, when the severity of the pain so increased as to 
become of a maddening character, and almost to produce delirium. 
The right portio dura nerve was paralyzed, and there was severe 
pain down the spine, which was attributed to a fall received when 
getting out of bed. The pulse did not warrant active depletion, but 
two or tbcw leeofaes were applied behind the affected ear ; a large 



402 THE DISEASES OF THE EAR. 

poultice was applied over the face ; the ear was gently syringed 
with warm water, and saline medicines were ordered. On the 18th 
she had some sleep in the night, but complained of an almost intoler- 
able pain in the back. The catamenia now appeared, and the cause 
of the pain remained obscure. She was quite sensible, the pupils 
acted, but the cornea on the affected side had begun to ulcerate. 
There was a slight discharge from the right ear, and the left had 
become somewhat deaf. It was thought that a hole could be ob- 
served in the membrana tympani : calomel and opium were admi- 
nistered. 

December 19th. — She has slept better and remained somewhat 
improved until five or six in the evening of the 21st, when she was 
suddenly seized with coma, and continued in that state until the 
following morning, when she died. 

Autopsy. — On examining the brain, slight sub-arachnoid effusion 
and vascularity of its surface were found, as also some increase of 
vascularity in the interior ; but there was no effusion in the ventri- 
cles. An abscess was discovered in the tympanum and labyrinth, 
and there was a counter-abscess, about the size of a large pea, in 
the condensed arachnoid and pia mater, occupying the fossa where 
the facial and auditory nerves proceed, from the junction of the 
medulla oblongata with the pons Varolii and cerebellum. Pus was 
effused beneath the arachnoid and pia mater, investing the right 
side of the upper portion of the medulla oblongata, and the adjoin- 
ing part of the right lobe of the cerebellum, to about the extent of a 
square inch ; but there was neither softening nor apparent lesion of 
the proper cerebral tissue beneath. 

The exact condition of the tympanic cavity and labyrinth is not 
detailed in the above notes by Mr. Streeter ; but there can be no 
doubt that the disease (most probably ulceration of the mucous 
membrane) had extended from the tympanum to the vestibule, 
either through the fenestra rotunda or ovalis, or by means of an 
orifice in the osseous wall of the labyrinth. The state of the portio 
dura and portio mollis nerves is not stated; but judging from the 
records of other cases of a similar character to the present, these 
nerves must have imdergone some morbid change and communicated 
the disease to the base of the brain. 

The remaining case is taken from M. Itard*s work,^ and is as 

' Traite des Maladies de TOreiUe, 1821. Tome i, p. 254, Obs. 22. 



NERVOUS DEAFNBSS. 403 

follows : A man, aged 22, five weeks before his death, complained 
of toothache: this was followed by febrile symptoms. On the 
twelfth day after the attack, discharge took place from the left ear, 
but symptoms of cerebral irritation increased until his death. 

Autopsy, — Over the convex surface of the brain, and in its sub- 
stance, were a number of small purulent deposits. The cerebellum 
was similarly affected, but in a less degree. The auditory and facial 
nerves were in a state of suppuration, and almost wholly destroyed : 
pus was also found in the internal auditory meatus, the vestibule, 
cochlea, and semicircular canals, and the tympanic cavity. 

The treatment to be pursued in these cases is similar to that 
recommended in cases of disease of the tympaniun and the mastoid 
cells. 



CHAPTER XVII. 



MALIGNANT DISEASE OF THE EAR. 



ORIGIN IN THE MUCOUS MEMBRANE OF THE TYMPANUM — DE8TRUCTI0K OF THK PETROUS 

BONB — SOMETIMES MISTAKEN FOR POLYPUS — OPERATIONS TO BB ATOIOSD BRAUT 

AND DURA MATER INVOLTED — ^TREATMENT. 



I 

Cases of malignant disease, advancing from the ear towards the 
brain, appear to be of rare occurrence. So far as my own expe- 
rience and the aid of published cases permit me to judge, it appears 
most probable that the part of the ear in which malignant disease 
usually originates, is the mucous membrane lining the cavity of the 
tympanum. After the diseased growth has destroyed the membrana 
tympani, it advances through the external meatus to the outer orifice, 
where it shows itself in the shape of a small tumor, which has 
sometimes been mistaken for a polypus, and the removal of which 
has caused hemorrhage and an aggravation of the symptoms. At 
the same time that the disease advances outwards, it also encroaches 
upon the whole of the parts surrounding the organ of hearing. The 
osseous walls of the meatus cxternus and of the tympanic cavity are 
wholly destroyed ; the outer part, and even the whole of the petrous 
bone, are converted into a mass of disease ; the lower part of the 
squamous bone also disappears, and the tumor advances into the 
cavity of the skull, where it destroys life, either by its pressure upon 
the brain or its bloodvessels, or by involving the brain itself in the 
disease. 

This malignant disease is sometimes of the nature of fungus 
haeniatodes ; at other times it has the characters of encephaloid 
disease. This affection occurs at various periods of life : the ages 
of the three patients to whose cases reference is about to he made 
were respectively 3, 18, and 35 ; the progress is very rapid gene- 
rally, and forms a marked contrast with those cases of chronic 



MALIGNANT DISEASE OF THK 



405 



disease of the ear ailvaricing to tlie britin, to which attention has 
hitherto been drawn. 

Sophia W., aged 35, a single woman, was admitted under my care 
into St. Mary's Hospital, on the 14tli Jnly, 1854. The history, as 
given by herself, is, that after ix severe cold, a year previously, the 
right ear suddenly became painful, though the pain was not very 
severe. Since the above period, the pain has been gradually in- 
creasing, accompanied by a tumefaction of the right side of the face- 
Six months ago a red growth was removed from the tube of the ear, 
which the surgeon considered to be a polypus, and since then she 
has had at times a good deal of bleeding from the ear. Lately the 
pain has greatly increased, and has extended over the side of the 
head and the face ; a small round swelling has also appeared at the 
orifice of the ear. On examination, the external ear was observed 
to he much redder than natural, and somewhat hyperlropbied ; and 
the orifice of the meatus was closed by a red tumor, about the size 
of an almond, upon pressing one side of which a small quantity of 
Banious discharge issued from the meatus. The integuments around 
the ear, for the distance of an inch and a half, were red, soft, and 
somewhat elevated above the surrounding parts by a tumor beneath 
them. The left portio dura nerve was completely paralyzed ; thoro 
was much pain of a pricking and shooting character complained of 
in the region of the tumor, and this at times extended inwards to 
the brain. The treatment consisted in occasionally applying a leech 
or two in the region of the ear, so as by diminishing the congestion, 
to relieve the pain ; small doses of morphia were frequently admin- 
istered, and the general health supported ; the meatus was frequently 
syringed with warm water, and emollient applications made to the 
tumor. These remedies, however, led to very transient amelioration 
of the symptoms ; though the pain would sometimes subside, the 
patient was subject to frequent and severe relapses, She was able, 
however, to walk about the ward, and a few days previous to her 
death expressed a wish to leave the hospital in order to visit her 
friends in the country. On the 23cl of October, she did not com- 
plain more than usual of the pain in the face and head, but on the 
24th and 25th there were symptoms of considerable cerebral conges- 
tion, she wandered a good deal, and the head was evidently a source 
of great distress to her. The symptoms of congestion gradually in- 
creased, and she died on the 28th of October. 

Autopst/. — The integuments of the external ear, and those cover- 



406 THB DISEASES OF THE EAR. 

ing the tumor, were red and tumefied. Upon reflecting the ear and 
the integuments from the tumor, a large mass was exposed, which 
extended from the posterior part of the mastoid process, posteriorly, 
to the body of the malar boixe anteriorly, and also from half an inch 
below the squamous suture to the angle of the inferior maxilla 
below. The tumor was intimately connected with the integuments, 
and of a reddish-white color. It presented different degrees of con- 
sistence, being in front, where it surrounded the ascending ramus of 
the lower maxilla, quite hard and firm like the pancreas, while more 
posteriorly it was softer ; and deeper towards the styloid process, 
there was a large quantity of a white creamy fluid. Both anterior 
and posterior to the external auditory meatus, the tumor contained 
small spiculae of bone. The mastoid process was involved in the 
disease, and was deduced to some detached masses of bone in the 
middle of a portion of the tumor. The osseous meatus had wholly 
disappeared, and the remains of the membranous meatus could 
scarcely be distinguished, its walls having become so much involved 
in the diseased mass. The only remains of the tympanic cavity 
were some portions of the mucous membrane, having a dark livid 
hue, with distended bloodvessels, and small red growths attached to 
it. Not a remnant was left of the bony cavity. The whole of the 
squamous bone, from an inch below the squamous suture, and the 
whole of the outer part of the petrous bone had been destroyed, so 
that the apex of the petrous bone had no connection with the squa- 
mous. The tumor had advanced inwards to the cavities of the 
cerebrum and cerebellum, through the aperture formed by the 
destruction of the squamous and petrous bones. In the middle 
cerebral fossa was a reddish-white tumor, of about the size of a small 
pear, which consisted of two portions, one below, and the other 
above, the dura mater. The part below the dura mater was directly 
continuous with the external tumor, while the large portion above 
seemed to be an independent growth from the free surface of the 
dura mater, and connected to the larger mass of the tumor by 
bloodvessels only. The upper part of this portion of the tumor 
was adherent to the lower surface of the left middle cerebral lobe, 
which was softened to the depth of half an inch. The part of the 
tumor posterior to the petrous bone, and beneath the tentorium, was 
somewhat smaller and less prominent than that just described in the 
middle cerebral fossa, was wholly confined to the interior surface of 
the dura mater, and must have almost entirely arrested the circula- 



ANT DISEASE OF THE 



407 



tion of tlie lateral sinus. The whole of the cerebral veins and 
sinuses were very mnch distended with dark-colored blood, but 
there was no appearance of disease in any other part of the cerebral 
substance than the softened portion of tbe inferior lobe. 

On examining the tumor by the aid of the microscope, the liarder 
portions were found to consist of very delicate fibres and nucleated 
cells, while the softer parts and creamy fluid were almost wholly 
composed of nucleated cells, circular, fusiform, imd angular. 

There appears every reason to believe that, in this case, the dis- 
ease originated in the tympanic cavity. It will have been seen that 
the seat of the pain when first complained of, was the ear. This 
was followed by a growth from the meatus, simitar to a polypus, and 
then by paralysis of the portio dura nerve. From this centre the 
disease seems to have spread in all directions, destroying every 
structure which it iippronohed. In the preparation, a large portion 
of the osseous wall of the cranium is seen to be absent, so that, by 
pressing upon the tumor during life, the contents of the cerebral 
cavity were also subject to pressure. Unfortunately in these cases, 
little can be done even to alleviate the suflerings of the patient, 
Local depletion by leeches applied to the vicinity of the tumor, hot 
fomentations and the administration of opiates, appear to be the 
only remedies capable of doing any service. It is nevertheless of 
the utmost importance to be able to decide upon the nature of the 
disease whenever it does occur, since measures will at least be re- 
frained from that arc calculated to aggravate the disease, aud no 
operation will be attempted. In the case in question, it is possible 
that the removal of part of the tumor, which was thought to bo 
a polypus, did material injury, by causing the disease to advance 
more rapidly. Those who are careful will have no difficulty in dis- 
tinguishing between an ordinary polypus growing from the walls of 
the meatus, and a portion of tumor similar to that of the case under 
discussion. The polypus is smooth and globular, and not covered 
by epidermis ; neither does it present an ulcerated surface, such as 
would be disclosed by a portion of encephaloid tumor when it exists 
and gives off secretion. Again, in cases of polypus growing from 
the external meatus, there is very rarely any tumefaction of the 
ear or integuments, such as is found in malignant disease. The ob- 
servation, so frequently made by me, may here be repeated, that as 
polypoid growths are so often symptomatic of the existence of iitI- 
tation within the tympanic cavity, and are sometimes coexistent 



408 



ABES OF THB EAR. 



with disease of the bone, grent caution should always be used prf^ 
vious to proceeding to extirpation. By referring to a very inberesl- 
ing case of malignant disease of the ear, published by Mr, Wilde at 
page 206 of his treatise on Aural Surgery, it will be found thai he 
also lays much stress upon the necessity of being careful " iu med- 
dling with morbid growths of long standing, without being fully 
satisfied as to their nature, and the place from which tliey grow." 
The cause of death in the patient whose case has here been con- 
eidered, appears to have been congestion of tbc brain, produced by 
the pressure of the tumor on its sabstancc, as well as upon the 
lateral sinus. 

The second preparation illustrative of the effects of malignant 
disease of the ear extending to the brain, which has to be described, 
■was laid before the Pathological Society of London, in 1850, by 
Mr. Cooper Forster, to whom I am indebted foij the specimen. The 
particulars, copied from the Tranmetion» of the Pathological So- 
eietff, are as follow : — 

" A strumous lad, aged 19, was knocked down by a cab nineteen 
months before bis death, and struck on the right side of his head. 
He soon afterwards became deaf, and suffered severe pun in tho 
right car ; tho part became slightly swollen and excessively tender, 
especially over the mastoid process. The swelling did not increase, 
but the pain in the heail was most intense, and paralysis of the 
right portio dura nerve look place. No great change occurred until 
within the last six months, when, from another blow on the samo 
spot, the disease seemed to become more active ; the side of the 
head, from above the temporal ridge to two inches below the ear, 
became enormously enlarged and tender; and the external ear ap- 
peared as though pusheil away from the side of the head. Ho ex- 
perienced great difficulty in swallowing solid food, and was also 
unable to speak. 

" About two months before his death, the swelling began to fan- 
gate and slough, profuse hemorrhage occurred at intervals, and 
sloughing very rapidly took place, and at last laid bare the pharynx. 
To such an extent, ultimately, had the destructive action taken 
place, that a large chasm formed around the ear, leaving that organ 
completely isolated. No brain symptoms occurred. The profuse 
hemorrhage and constant ilrain of pus quickly destroyed him. 

'^Autopn;/. — The brain appeared perfectly healthy except at tb« 
lower part of the right hemisphere, which was pulpy and vei 





MALIGNANT Dli 



OP THE EAR. 



409 



The softening was, without doubt, occasioned by the upward pres- 
sure of a hard scrofulous-looking mass, attached to the petrous 
portion of the temporal hone, through the intervention of the dura 
mater, from which it seemed to spring. The mass pressed upon the 
bone below, and appeared as though inclined to force its way down- 
wards, through tbe temporal bone, at the junction of the squamous 
with the petrous portion, a great part of the latter being completely 
absorbed. Some new bone had formed at the inner side, and the 
whole of the exterior was occupied by a sloughy mass and carious 
bone (as seen helow), the surrounding parts being very hyportrophied : 
no vestige of meatus or mastoid cells could be discovered ; the lateral 
sinus was filled by a eoagulum." 




From the history of the case just cited, and an examination of 
the preparation, there is no doubt on my mind but that the nature 
of the disease was malignant, very probably encephaloid, and that 
it commenced in the tympanic cavity. It will have been observed, 
that the early symptoms indicated that the disease was in the ear, 
both by the pain experienced there, and by the presence of deaf- 
ness. If the preparation be carefully inspected, it will be seen that 



410 THE DISEASES OF THE EAR. 

the largest amount of destruction, and the most marked appearance 
of disease, are around the tympanic cavity ; from which the progress 
seems to have been downwards to the pharynx, upwards to the 
outer surface of the squamous bone, and lastly, inwards and up- 
wards to the cavity of the skull. The orifice communicating between 
the disease without and that within, is, however, very small in com- 
parison to the extent of the disease externally, and the internal 
surface of the bone is much less afiected than the outer. That the 
disease was malignant is shown, I think, by the bleeding and fungoid 
character of the soft growth, and the peculiar expanded and spicu- 
lated state of the bone. 

The third case is one published in the eleventh volume of the 
Edinburgh Medical and Surgical Journal^ by Mr. Wishart, and 
called by him a case of fungus haematodes. The subject was a child 
three years old, in whom, after suffering for some weeks from severe 
pain in the right ear, followed by discharge, a tumor appeared 
surrounding the ear, and which speedily ulcerated, discharging a 
large quantity of fetid bloody matter ; hemorrhage also frequently 
occurred. The child died within fifteen weeks after the appearance 
of the disease. On a post-mortem examination, the tumor was 
found to be as large as the child's head ; externally it had caused 
the destruction of the condyloid process of the lower jaw ; the 
zygomatic process was also gone. The tumor had advanced inwards, 
destroying the whole of the petrous bone, and extended upwards, 
through a large orifice in the squamous bone, so as to form a de- 
pression on the middle lobe of the brain, which was in other respects 
quite sound. 

As bearing upon the subject, I may as well give briefly the par- 
ticulars of a case of disease of the petrous bone which occurred in 
the practice of Mr. Part, of Camden Town, to whom I am indebted 
for the preparation. The patient was a clergyman, aged twenty- 
five, subject for five years to a discharge from the right ear, with 
occasional pain. A year before his death an abscess broke behind 
the ear, which discharged at times. About a fortnight before his 
death he suffered from severe pain in the head and vomiting, and 
had paralysis of the right portio dura nerve. He was not relieved 
by any treatment, and the head-symptoms increased until his death. 
On a post-mortem inspection, a cavity was found in front of the ear, 
and another beneath the temporal muscles ; both contained a soft 
caseous substance. The whole of the petrous bone, a portion of the 



MALIGNANT DISEASE OF THE EAR. 411 

basilar process of the occipital and of the sphenoid, were found de- 
generated into a soft cheesy mass. The malar bone was destroyed, 
and the mastoid process occupied by the disease. The ventricles 
contained three ounces of bloody serum ; the arachnoid was much 
injected ; while between it and the pia mater was a layer of very 
yellow pus, extending along the base of the brain. In the middle 
lobe of the brain was an abscess containing upwards of an ounce of 
very fetid greenish pus ; and a second abscess existed in the middle 
of the posterior lobe. If the preparation be examined, as in the 
preceding cases, there will be found to be a large aperture in the 
squamous bone, and the petrous and mastoid bones are wholly con- 
verted into the white cheesy-looking matter. On examination by 
the microscope, this matter is discovered to consist of cells, varying 
in form, only few of which have any distinct nuclei; granular 
matter is also interspersed among the cells. The case may be con- 
sidered as one of degeneration of the petrous bone, originating in 
the tympanic cavity. 

The ulceration at times proceeds most rapidly, extending to the 
bone, which is soon destroyed. Sometimes the greater part of the 
squamous bone disappears. A case of the kind has been published 
by Dr. Russell, of Birmingham, in the Association Journal^ for March 
31st, 1852, of which I will give a few particulars. 

Mrs. P., aged 66, was attacked, about nine months before her de- 
cease, with pain in the right ear, attended with swelling. A fort- 
night afterwards, she struck it against a bracket ; the swelling broke, 
and the car discharged. The discharge and pain continued, and 
paralysis of the portio dura ensued, while the power of hearing dis- 
appeared. At the time she was seen by Dr. Russell, there was in- 
tense pain in the ear ; mania, coma, and ultimately death, ensued. 
There was no history of early disease in the ear, but she had been 
accustomed to pick it with a pin, for a certain degree of itching. On 
an autopsy, the entire squamous portion of the temporal bone was 
found to have been destroyeil, and the disease had encroached 
upon the mastoid process, laying open the cells. The petrous 
bone was also almost entirely destroyed. The dura mater was not 
injured, except in one spot, where there was a sloughy opening, the 
size of a crown-piece. Opposite the orifice in the dura mater, the 
brain was in a state of suppuration ; and both ventricles were full 
of the debris of sloughy cerebral tissue. There were about two 
drachms of thin, purulent fluid at the base of the brain. This spe- 



412 THE DISEASES OF THE EAR. 

cimen, which through the kindness of Dr. Russell I had an oppor- 
tunity of inspecting, presented a very similar appearance to the one 
previously described. In each case all vestiges of the tympanic 
cavity had disappeared. They differ from the great majority of 
cases of disease in the tympanum, in extending outwards instead of 
upwards. 

The treatment in these cases consists in diminishing the symptoms 
of congestion of the brain, by the occasional application of leeches, 
and in attempting to allay the pain by the administration of mor- 
phia. 




ON THE DEAF AND DUMB. 



The number of deaf-mute children examineii, anii from whom 
the facts in this chapter were obtained, amounted to 411. Of these, 
313 were congenital cases, and 98 were the effect of different dis- 
eaaee acquired subsetjnent to birth. 

I. THE DISEASES PRODCCINIJ DEAF-MCTISM. 

On the causes producing congenital deaf-mutism I am unable to 
offer a decided opinion ; but the results of dissection, as detailed in 
a subsequent part of this chapter, show that the nervous apparatus 
is very frequently affected. If regard he also paid to the other 
oases I shall refer to, and the non-appearance of an efficient cause 
of any other kind, together with the analogy to be drawn from the 
cases in the chapter on Nervous Deafness, it would be no very 
violent assumption to suppose that early derangement of the nervous 
apparatus is at the root of most of tbc instances of deaf-mutism. 

Of the causes of acquired deaf-mutiam a more accurate estimate 
may be formed. Thus in the 98 cases of acquired deafness the 
causes were as follows : — 



I, bydrocephktaa, ■> fall, tiia, ■ 



414 THE DISEASES OF THE EAR. 



II. THE CONDITION OF THE EARS IN THE DEAF AND DUMB, AS 
ASCERTAINED BY EXAMINATION DURING LIFE. 

The condition of the ears in the deaf and dumb is very various, 
and in the majority of the cars there is some abnormal appearance, 
although it is often very slight. Thus, in only 197 out of 411 
patients were the ears healthy. The following table shows the con- 
dition of those ears that were not healthy : — 

In 66 the surface of the membrana tympani was dull. 
38 the membrana tympani was opaque. 
12 the membrana tympani was more concave than natural. 

8 the membrana tympani was very concave and opaque. 

1 the membrana tympani was shrivelled. 

10 the membrana tympani had fallen inwards. 

9 the membrana tympani was perforated. 

18 the membrana tympani was absent, from ulceration. 

2 the meatus was full of cerumen. 

85 the meatus was full of cerumen, and the membrana tympani 

opaque. 
8 the meatus externus formed a cul-de-sac half an inch from the 

orifice. 
i. the meatus contained a polypus. 

3 the membrana tympani of one ear was opaque, and in the 

other it had fallen inwards. • 
2 the membrana tympani was opaque in one ear and absent in 

the other. 
1 the membrana tympani was normal in one ear and absent in 

the other. 
8 the membrana tympani was fallen in in one ear and perforated 

in the other. 
1 the membrana tympani was natural in one ear and the meatus 

full of cerumen in the other. 
1 the membrana tympani was fallen in in one ear and dull in 

the other. 
1 the membrana tympani was absent in one ear and the meatus 

contained a polypus in the other. 
1 the membrana tympani was very concave in one ear and had 

fallen inwards in the other. 



ON THE DEAF AND DUMB. 



415 



In 1 the membrana tympani was natural in one ear and very con- 
cave in the other. 
1 the membrana tympani waa perforated in one ear and opaque 

in the other. 
1 the membrana tympani was very concave in one ear and absent 
in the other, 

It is interesting to observe the difference between the condition 
of the ears in the acquired and congenital cases. 

The condition of the ears in the 313 congenital eases : — 

172, or nearly three-fifths, had a natural appearance. 

In the 172 cases of absolute deafness tlie following was the con- 
dition of the ears; — 

QG had a healthy appearance. 
In 37 each membrana tympani was (.lull. 

20 there was an accumnlation of cerumen, and each membrana 

tympani was dull. 
12 each membrana tympani was opaque. 

1 each membrana tympani had been destroyed by ulceration. 

2 one membrana tympani was opaque, the other had fallen in. 
1 one membrana tympani waa opaque, the other was absent. 

1 one membrana tympani was natural, the other was opaque. 
1 one membrana tympani waa natural and the other waa absent. 
1 one membrana tympani was fallen in and the other was per- 



forated. 



172 



The following was the condition of the cars in the 141 congenital 
eases, in which certain sounds viore heard : — 

(a.) In 11 who heard a clapping of the handa, 7 had a normal 
aspect. 
In 2 each membrana tympani was opaque. 

1 each meatus waa distended by cerumen, and the membrana 

tympani waa opaque. 
1 each membrana tympani was c 



416 THE DISEASES OF THE EAB. 

(6.) In the 44 who heard a shout : — 

21 were apparently natural. 
In 7 each membrana tjmpani was dull. 



4 


(( 


u 


u 


" and the meatus full of 
cerumen. 


4 


(( 


u 


a 


opaque. 


4 


(( 


u 


« 


concave 


2 


a 


u 


(( 


concave and opaque. 


2 


n 


a 


(( 


perforated. 



(<?.) In the 89 who heard a loud voice : — 

24 were apparently normal. 
In 7 each membrana tympani was dull. 

3 " " " " and the meatus full of 

cerumen. 
3 " " " opaque. 

1 " " " concave. 

1 in one ear the membrana tympani was normal ; in the other 
it was opaqui), and the meatus full of cerumen. 

(rf.) In the 43 who heard the vowels and repeated them after 
me: — 

24 appeared to be normal. 
In 6 each membrana tympani was dull. 

5 " " '' " and the meatus was full of 

cerumen. 
5 " " *' opaque. 

1 " " " concave and opaque. 

(e.) In the 5 who heard words and repeated them : — 

2 appeared normal. 

In 1 each membrana tympani was dull. 

1 " '' " " and the meatus was full of 

cerumen. 
1 in one ear the membrana tympani was opaque and concave, 
and in the other it had fallen in towards the promontory. 

(/.) In the single instance in which short sentences were heard 
and repeated, the membrana tympani was dull. 



ON THE DEAF AND DUMB. 417 



The condition of the ear in the 98 acquired cases of deafness. 

Of the entire number, only 23, or about one-fourth, had a natural 
appearance ; of the 75 cases of acquired deafness, in which there 
was no power of hearing, 19, or about one-quarter, were apparently 
normal ; including those instances in which the surface of the mem- 
brana tympani was only slightly dull, 27, or about one-third of the 
whole, had a natural appearance. Of the 25 acquired cases in which 
there was a certain amount of hearing power, 5, or one-fifth, were 
apparently healthy. 



Scarlet Fever, 

In the 86 cases of scarlet fever, only two patients had the ears in 
a healthy state ; in 15 each membrana tympani was absent, and in 
5 each membrana tympani was perforated ; in 3 each meatus formed 
a cul'de-sac about half an inch from the orifice. It is clear, there- 
fore, that in the majority of cases of deafness from scarlet fever, the 
effects of very active disease were apparent ; this disease was usually 
catarrhal inflammation of the tympanic mucous membrane, ending in 
an ulceration of that membrane, which extended to the labyrinth. 
As it is interesting to observe the relation between the amount of 
hearing possessed by a patient, and the condition of the ears, I have 
arranged the results in the following forms : — 

(a.) Condition of the ears in the 27 patients who were entirely 
deaf : — 

In 1 each ear was apparently healthy. 

4 the surface of each membrana tympani was dull. 

1 each membrana tympani was concave. 

2 " ** " fallen in. 

8 " " " perforated. 

13 " " " absent, and there was catarrh 

of the tympanic mucous membrane. 

3 each meatus formed a cul'de-sac about half an inch from its 

orifice. 

(b.) Condition of the 9 patients by whom certain sounds are 
heard ; — 

27 



418 THE DISEASES OF THE EAB. 

In the single individual who heard a clapping of the hands, each 

membrana tympani was absent. 
Of the jive who heard a loud voice : — 
In 1 the membrana tympani was fallen in. 

2 " " " perforated, and there was a poly- 

pus in the meatus. 

2 " " " absent in each ear. 
Of the two who pronounced the vowels : — 

In 1 the membrana tympani was dull and opaque. 

1 in the right ear the membrana tympani was fallen in ; in the 
left ear it was absent. 

In the one child who pronounced short words both ears were appa- 
rently natural. 

Condition of the ears in the 28 cases of deafness from fever : — 

(a.) In the 17 who did not hear any sound : — 

3 were apparently healthy. 

In 2 each meatus was distended by cerumen. 
3 each membrana tympani was opaque. 
1 " " " dull. 

1 " " " white and shrivelled. 

2 " " " fallen in. 

1 " " *' perforated. 

1 " " " destroyed by ulceration. 

1 each meatus full of paper, each membrana tympani fallen in 

and red. 
1 right oar, the membrana tympani concave and thick ; left ear, 

membrana tympani perforated and fallen in. 
1 right car contained a polypus; in left ear the membrana 

tympani was absent. 

(6.) In the 6 who heard sounds. 
In the four who heard a shout : — 

1 each membrana tympani was dull and opaque. 
1 " " " perforated; the mucous mem- 

brane of the tympanum being thick. 
1 each membraiiji tympani was dull. 

1 right ear, the membrana tympani was perforated ; left ear, 
the membrana tympani fallen in and corrugated. 



ON TlIE DEAF AND DUMB. 



419 



In the single instance in which a loud voice was beard, each mem- 
hrana tympani was opaque; and in the case whore the patient tried 
to articulate words after the Bpoaker, each ear was apparently 
normal. 



Oondition of the ear in the four casns of measles : — 

(a.) Of the three who were deaf; — 

In 1 each ear was apparently normal. 

1 each membrana t3nnpani white and thick. 
1 right ear, the mcmbrana tympani dull ; left ear, racmbrana 
tympani dull, and fallen in. 

(6.) In the patient who heard a clap of the hands, each mcmbrana 
tympani was thick and white. 

Co-ndition of the ear in the 35 cases of deafness produced by va- 
rious diseasesy as teething, convulsions, hydroeephahts, a fall, fits, a 
fright, 4-c. : 

In seventeen cases each ear appeared to be normal. In several of 
the others the membrana tympani was dull on the surface, opaque, 
or concave. In three cases it had fallen in ; but in only two was it 
perforated : thus showing a marked difference between the effects of 
these diseases and those of scarlet fever; where it will be remem- 
bered that, in 20 out of 36 cases, each membrana tympani was 
either absent or perforated. I will give, first, the condition of the 
ears in the patients entirely deaf, and then the condition of those 
having various degrees of hearing. 



(a.) Condition of the 
deaf; — 



ars in the 26 patients who were entirely 



14 appeared natural. 
In 2 each membrana tympani was dull. 
3 " '* opaque. 



fallen in. 



». 



420 THE DISEASES OP THE EAR. 

1 one ear appeared natural ; in the other the membrana t jmpani 

was fallen in. 
1 in one ear the membrana tympani was opaque ; in the other it 

was absent. 
In the case where the clap of the hands was heard, each ear ap- 
peared to be natural. 

* (J.) Of the three who heard a shout : — 

1 appeared to be natural. 
In 1 each membrana tympani was opaque. 

1 the membrana tympani of one car was concave, and it was na- 

tural in the other. 

(<?.) Of the four who heard a loud voice : — 

1 appeared natural. 
In 1 each membrana tympani was opaque. 

2 the membrana tympani of each ear had fallen in. 

In the single case where the vowels were heard, the membrana 
tympani of one car was opaque, and it was perforated in the other. 



III. ON TUE CONDITION OF THE EAR IN THE DEAF AND DUMB, AS 

REVEALED BY DISSECTION. 

It is highly desirable that careful dissections should be made of 
the ears of deaf and dumb patients whose cases have been carefully 
noted during life, in order that the condition of the organ may be 
compared with the amount of hearing possessed by the patient. Pa- 
thological investigations into the condition of the ear in the deaf and 
dumb have, however, been too seldom conducted, to enable us to 
draw any conclusive general deductions as to the condition of the 
ear in deaf-mutes. I purpose now to give the details of five dissec- 
tions performed by myself, and to follow them with a tabular view 
of the morbid appearances found in all the other dissections of simi- 
lar cases that have been met with by me. 

Dissection 1. — A woman, ret. 40, deaf, and consequently dumb, 
from birth. For the last ten years of her life she was insane, and 
was confined in a lunatic asylum. The petrous bones were sent to 



ON THE DKA 



me, immediately after the death of the patient, by the late Mr. 
Croase, of Norwich. 

Right ear. — The meatus extemus, membrana tympani, and the 
tympanic cavity were in a healthy state. Labyrinth. — The anterior 
limb of the superior semicircular canal communicated with the ves- 
tibule, but w»s rather larger than natural, and its shape somewhat 
irregular. Examined as it passes inwards, it was observed to ter- 
minate in a cul-df-»ac, after having attained only balf its usual 
length. The portion of bone in tbe situation usually occupied by 
the inner part of tbe canal was of an ivoid whiteness, and could be 
distinctly distinguished from the surrounding bone. The greater 
part of the posterior semicircuiur canal was absent, its anterior and 
posterior extremities presenting two cul-dc-sae», balf a line in length. 
The external semicircular canal, the vestibule, and cochlea, were in 
a normal state. 

Xp/( car. — The superior semicircular canal is in the same incom- 
plete state as that of the right ear. 

Dissection 2. — J, C, xt. 50, died from fever. He was bom 
deaf, and had been educated as a deaf-mute. 

Right ear. — Meatus externus in a natural state, excepting that 
one part of the osseous parietes was quite rough. Membrana tym- 
pani thicker than natural, and perforated : a small red polypus was 
attached to its dermoid layer. A membranous band connected the 
stapes, incus, and tensor tympani muscle. The osseous semicircular 
canals were large ; but they did not contain any membranous tubes. 
The cochlea was in a normal state, as were also the tympanic muscles 
and nerves. 

Left ear. — The osseous semicircular canals did not contain any 
membranous tubes. One of the osBcous canals was so contracted as 
to admit of the passage through it of a fine wire only. 

Dissection 3. — B. B., let. 16, a girl, sharp and intelligent. 
Her parents stated that she was born deaf ; but tbe child, on the 
contrary, said that she had heard sounds. Her teacher thought 
the child's statement to be more likely to be correct, as she pro- 
nounced many words according to their proper sounds. None of 
her relatives were deaf-mutes. Upon making a careful dissection of 
each ear, no deviation from tlio normal condition could be detected 
in the meatus externus, membrana tympani, or tympanic cavity. 
The stapes adhered to tlie fenestra ovalis with its usual degree of 
firmness. The membranous labyrinth in the vestibule was healthy, 



422 



08 also vaa that in tho Hemic!rcular CEtnals, with this exception, that 
in the midiile of the superior semicircuhir canal in the right ear was 
a quantity of otoconie (ear crystals), which completely obstructed 
the tube. 

From the occurrence of an accident to the left ear, it was not 
possible to ascertain its condition. 

DiSB&CTiON 4. — A boy, set. 15, who had been wholly deaf from 
Ilia birth. Ko deviation from the normal state in either ear could 
be detected by me. 

Dissection 5. — For the opportunity of making this disscetion, I 
am indebted to Dr. Ormerod, of Brighton. The ears were taken 
from a young woman deaf and dumb, with discharge from each ear. 
She died with tubercular inflammation of the brain. 

Right ear. — The membrana tympani was absent; the mucons 
membrane of the tympanum red, and of extreme thickness, so as to 
fill the whole of tho tympanic cavity and to conceal the stapes ; the 
tympanum waa distended with dark-colored blood. The petrous 
bone was so intensely hard, that it could with difficulty be cut by 
the hone forceps. Tho cochlea, to the naked eye, had a natural 
appearance, and submitted to microscopic examination, no deviation 
from the normal structure could be detected, excepting in that por- 
tion of the lamina spiralis whicli is near to the vestibule. This, 
instead of being composed of a delicate osaeous lamina and a fine 
membrane, the two making a delicate septum between the seals 
tympiini and scala vestibuli, presented a mass of solid bone filling 
up the scala tympani, and concealing from view the membrana 
feneatrje rotundje ; the inner surface of which it wholly covered. 
The outer Burface of this membrane could, however, be distinctly 
seen from the tympanic cavity, and it appeared natural. 

The semicircular canals contained more otoconie than natural. 

Lfift ear. — The membrana tympani absent. The mucous mem- 
brane of tho tympanum thick and red, as in the right ear. The 
semicircular canals contained more otoconie than natural, and espe- 
cially the posterior one, which, at its junction with the posterior 
limb of the superior canal, was wholly distended with crystals for 
the extent of half a line. The lamina spiralis of the cochlea was 
of a deep red color, and blood was effused in both scalie. The part 
of the lamina spiralis near to tho vestibule was in the same state as 
the same portion in the right ear. 

In the subjoined table the condition of the ears in deaf-mutes, as 
revealed by various reported dissections, is shown. 




ON THE BEAF ANB DUMB. 



428 



A TABULAR VIEW OP THE CONBITION OP THE EAR IN THIRTY-SIX 

DISSECTIONS OP DEAP-MUTBS. 



Meataa 
Bzternus. 


Membrana 
TympanL 


Tympanum. 


Labyrinth. 


Neire. 


Name of 
Obaeirer. 


Absent. 




• • • 




As soil as 
mucus. 


Itard. 


Absent. 


• • • 


• • • 




• • • 


Pabricius. 


Absent. 


• • • 


• • • 




• . ■ 


Do. 


• • • 


• • • 


• • • 




• . • 


Itard. 


• • • 


Destroyed. 


Containing vege- 
tations from the 
mncons mem- 
brane ; ossicles 
absent. 




• ■ • 


Do. 


• • • 


Do. 


Do. 


• • • 


... 


Do. 


■ • • 


Partially 
destroyed. 


Containing sorofti- 
lons matter. 


• • • 


• . . 


Mr. Cock. 


• • • 


Do. 


• • • 


• • • 
• 


. . • 


Do. 


• • • 


Do. 


• • • 


• ■ • 


• • • 


Do. 


• • • 


• • • 


Containing caloa- 
reons concre- 
tions. 




« • . 


lUrd. 


• • • 


• • • 


Full of gelatinous 
matter. 


Pull of gelatinous 
matter. 


... 


Do. 


• • • 


• • • 


Containing a yel- 
low fluid. 


• • • 


Harder 

than 
natural. 


Rosenthal. 


• • • 


• • • 


Anchylosis of 
stapes to fenestra 
oyalis. 


• • • 


■ • • 


Valsalva. 


• • • 


• • • 


All the ossicles 
wanting. 


• • • 


• • ■ 


Reimarus. 


• • • 


•. • • 


• • • 


Vestibule full of 
caseous matter. 


• • • 


Dr. Haighton. 


• • • 


• • • 


• • 


Cochlea consisting 
of only one turn 
and a half. 


• • • 


Mundini. 


• • • 


• • • 


■ « t 


Vestibule, coch- 
lea, and semicir- 
cular canals ab- 
sent. 


■ • • 


Meckel. 


• • • 


• • • 


• • • 


Semicircular ca- 
nals wanting. 


• t • 


Murer. 



* Where no entry is made, it is to be assumed that the part of the organ was in a 
healthy state. 



TBB DISEASES OF THE EAB. 



UmIiu 


Tjniiwil. 


Trnpuom. 


UbjUBlli. 


Ke^e. 


Obrma. 




Parliall; 
dwlroyad. 


All tha ouielai 

■uiting. 


Two or tbe lemi- 
oirculir MDkU 
imperfect. 

Do. 

... 

Feneitr* rotnodk 
closed bj bone ia 

Ona lamielrontar 

henltby. 

Aqnsdnclni Taiti- 
buli Tary Urge. 

naliabaantinotie 


Atrophied. 
WuitiDK. 

Vary hard. 


Hr. Cock. 

Do. 
SylTini. 
Anuneu. 
H«,K.,^i. 
Sir. Coak. 

R0MDth>l. 

Murer 

1 








Filled with Duaciu 
mkttar. 


Half !t> 
niaal >i». 

Atrophied. 

CoiDpreMad 


Dr. Hai^hlon.; 
HafRoan. 1 








A portion ot one of 
tha membruKin* 

D»l« filled with 
otoconie. 




Author. j 








Tha anperior nnd 
pcplarior icmicir- 
oulBr c«n«li. in- 




Do. 

! 








ciiUDlai cuiali 

ftbKDt. 




Do. 
So. 




D..lrojBj. 


Mncouf 
numbr&na thick. 


Lamina cpiralis Oloconie ob- 
nearthavertibula, rtrueting 
filling tha KKln Iha oanali. 
tyto^ni. 1 


D«. 



OK THE DEAF AXD DUMB. 



IV. ON THE MODE OP EXAMININO A CHILD SUPPOSED TO BE DEAF 
AND DUMB. 



From the absence of precise experimentB from vrhtch accurate 
conclusioDB could be drawn, great (Ufference of opinion frequently 
esists, even among medical men, as to whether a child suspected of 
being deaf and dumb really ia so. 

It frequently happens, therefore, that a child ia reported not to 
be deaf, because it always starts or looks up when the door of the 
room is loudly knocked, or the floor over the room ia tapped with 
considerable force, or the fire-irons in the room are permitted to 
fall, or the piano is played. A eimilar opinion ia often formed 
because a child can utter some short syllables, as "Mam," "Pa," 
&c., it being argued that no child could learn to utter these sounds 
unless it had heard them. It ia also asserted, that a child could 
not have been born deaf, because the defect was not discovered until 
it had reached the age of a year ami a half or two years. 

In reply to the above arguments in favor of a child's being able 
to hear, it must be borne In min<I that loud sounds are always 
accompanied by more or leas vibration of the walls and floor of the 
apartment, which can he felt by a person whose attention may thus 
be attracted, although totally deaf. A child may also learn to utter 
short words by simply imitating the movements of the lips of the 
parent, or nurse, without the exercise of the sense of hearing. The 
plan adopted by me to ascertain whether a young child is deaf, con- 
sists, in the first place, of allowing it to sit on the knee of the 
nurse or parent, and be amused by something, and then while its 
eyes are fixed upon the object, to speak loudly, or shout, taking 
especial care that the breath does not reach the patient. Again, 
let the child, its attention distracted as before, be placed with its 
back towards the surgeon, who should, when near it, clap his hands 
loudly, ring a large bell, or blow a powerful whistle, always taking 
oare that his ovnx shadow is not seen, and that the child is screened 
from the movements of the air, while the nurse is warned not to 
start or suddenly look up ; or the surgeon may come into a room, 
the door of which has been some time open, and where the child ia 
seated with its back towards him surrounded by toys, and perform 
similar experiments. If the child docs not evince any symptom of 
hearing, by suddenly lifting up its eyes, turning round, or starting, 



4-26 THE DISEASES OF THE EAR. 

it must be concluded that it is wholly deaf; but if, on the contrary, 
it looks up each time the surgeon shouts, or tama round quickly the 
instant the hands are clapped, it is evident that some power of 
hearing exists, and steps should be taken to ascertain the extent of 
such power, and how far it may enable the child to be orally taught. 



V. ON TEE UBDICAL TREAT^IfNT OF THE DEAF AHD DUMB. 

It is of great importance that the surgeon should be able to decide 
what treatment, if any, should be pursued when deaf and damb ^ 
children are brought to him. 

The first rule which may be laid down is, that in those casea I 
where there is no hearing power whatever, and in which it is sup- 
posed that the nervous apparatus is either incomplete or much dis- 
organized, no treatment for the purpose of improving the hearing 
should be resorted to. The friends of the child should be told that 
there is no hope of any change, and that it will have to he educated 
as a deaf-mute. 

On the contrary, should there be a certain decided amount of 
-hearing power, some attempt, it is obvious, should be made to de- 
velop it. Where the child is evidently born deaf, general medicinal 
treatment is not required ; and the only remedy is the use of means 
to excite the nervous system of the cars to natural action. By the 
persevering nse of the long elastic tube, the hearing power lias, ia , 
some cases, been decidedly increased. 

In cases where by disease subsequent to birth, either the i 
brana tympani, or the mucous membrane lining the tympanum, hts ' 
been thickened, counter-irritation over the mastoid process will aid 
the use of trumpets ; and in those where the membrana tympani haa 
been partially or wholly destroyed by ulceration, and where there 
is a constant discharge of mucus from the surface of the tympanic 
mucous membrane, it is desirable for the ears to be syringed, and 
occasionally with a weak astringent, so as to prevent the membrane 
becoming ulcerated, and the bone which it covers, carious. The 
artificial drum may also be resorted to. 




OS TUB DEAF AND DUMB. 



VI. THE AMOUNT OF HEABINa P06BK8SKD BY CIIILBBEN EDUCATED 
AS DEAF AND Dl'UB. 

The examination of a large number of children usuallif considered 
to be wholly deaf, and consequently educated as deaf-mutes, shows 
that a large proportion are not totally deaf, but that, on the contrary, 
certain sounds are distinctly heard. Thus, it will be observed, that 
of the 411 children examined at the Deaf and Dumb Asylum, 245, 
or three-fifths, were quite deaf, not hearing any sound ; while 166, 
or two-fifths, heard certain sounds. The 166 cases in which certain 
sounds were perceptible, may be classified aa follows : — 

14 heard a clapping of the hands. 

51 heard a shout close to the ears. 

50 heard a loud voice close to the ears. 

44 distinguished vowels, and repeated them. 

6 repeated short words. 

1 repeated short sentences. 

166 

Of the 411 children it has already been stated thatSlSwere cases 
of congenital deafness, while 98 were acquired cases. 

Of the 313 congenital cases — 
172, or about five-ninths, were deaf — i'. e., no sounds were heard 

by them. 
141 heard certain sounds. 



313 congenital cases. 



The 141 cases in which certain Bounds v 
fied as follows : — 



! heard may be classi- 



11 heard a clapping of the hands near 1a the head. 

44 heard a shout, 

39 heard a lond voice, 

41 heard the vkhi-U, and repeated them. 
5 beard wi^rdu, ami r<rp4«t<54l them, 
1 heard Khort itcnttfnMS, utd reposted thota. 



428 THB BISEASES OF THE EAR. 

Of the 98 acquired cases — 

73, or about {hree-fourths were deaf. 
25 heard certain sounds. 

The 25 acquired cases in which certain sounds were heard may be 
particularized as follows : — 

Arising from scarlet fever , 9 : — 

1 hears a clapping of the hands. 
5 hears a loud voice. 
. 2 pronounce the vowels. 
1 pronounces short words. 

Fever, 6 : — 

4 hear a loud shout. 

1 hears the voice. 

1 hears the voice, and tries to imitate it. 

Measles, 1 : — 
1 hears a loud clapping of the hands. 

Various Diseases, 9 : — 

1 hears a loud clapping of the hands. 

3 hear a shout. 

4 hear a loud voice. 
1 repeats the vowels. 



VII. ON THE EDUCATION OF THE DEAF AND DUMB. 

The observations to be offered upon the system usually adopted 
for the education of the deaf and dumb, have reference to two points: 
first, the improvement of the power of hearing ; second, the use of 
the vocal organs. 



1. Of the improvevient of the power of hearing. 

It would be very interesting to know how far the facts respecting 
the hearing power of so-called deaf and dumb children, cited in a 



ON THE DEAF AND DUMB. 



429 



previous part- of this chapter, are corroborated by the observations 
of others. Itard hazarded the opinion that one-half of the pupils 
at the Deaf and Dumb Institution at Paris were wholly deaf, and 
that the other half heard some sounds. It is assumed by the writer 
of the very interesting article on the Deaf and Dumb, in the " Penny 
Cyclopiedia," that the same proportion of the totally deaf to those 
who hear a little, will b« met with in our English institutions. If 
there exist throughout the deaf and dumb in England relatively, as 
many cases of a large amount of hearing as in the London Institu- 
tion, steps taken to improve the hearing power might be productive 
of the moat valuable results; especially as my own limited experi- 
ence warrants the assertion that this power ia capable of considerable 
development, as may be seen by the cases appended. Though one 
of these does not belong to the category of the deaf and dumb, yet 
the long duration of nearly total deafness in one ear, followed by so 
great a restoration of its dormant power, renders the case of great 
interest in the present inquiry. The treatment calculated to im- 
prove the hearing, consists in the use of trumpets, whereby the 
nervous apparatus may be gradually ercited, as to become sensitive 
to ordinary sonorous undulations and external stimulants. While 
quite agreeing with Mr. Wilde, that we cannot hope to cure cases 
of deaf-mutism, I still think, when there already exists the power 
to hear the vowels so distinctly as to distinguish and repeat them, 
that from the exercise of the ear considerable improvement may 
reasonably be anticipated ; sufficient, in fact, to aid in carrying out 
the end above all things to be desired, viz., the exercUe of the orgatu 
ofgpeeeJt. 

The influence of the use of the vocal organs upon the general 
health baa, it seems to me. scarcely been sufficiently considered in 
the education of the deaf and dumb. Sir H. Uolland, with his 
osual acuteness, has placed the subject in its just light. He sorys : 
" Might not more be done in practice towards the prevention of 
pulmonary diseases, as well as for the improvement of the general 
health, by expressly exercising the organs of respiration; that is, 
by practising, according to some method, those actions of the body, 
through which the chest is alternately in part Elled or emptied of 
wr? Though suggestions to this effect occur in some of our best 
works on Consumption, as well as in the writings of certain conti- 
nental physicians, they have hitherto had less than their due in- 
fluence, and the principle as such is little recognized or brought 



4S0 



THE DISEASES OF THE 



into general application. In truths common usage takes, for tl 
most part, a directly opposite course, and. under the notion m 
pretext of quiet, seeks to repress all direct exercise of this impi^ 
tant function in those who are presumed to have a tendency 
pulmonary disorders." — Medical Notes, c. xx, b. 422. 

To this, I may be allowed to add, in reference to the deaf ai 
dumb, that in those cases where the organs of speech are not ds< 
and where, consequently, the lungs, and the muscles of the che 
and heart, are not duly exercised by the act of articulutioD, t 
general health always suffers. 

But the groat advantage of calling forth the auditory power 
so-called doaf-rautes is, that they may be enabled to hear their w 
voices, and to modulate them ; for the extreme harshness & 
monotony of the sounds produced by deaf-mutes, arise from the ii 
possibility of regulating the tones of a voice which they 
distinguish. 



Miss L. L., S2t. 23, consulted me in the early part of the yet 
1857. Her history was, that since childhood she had heard on] 
certain loud sounds, and was quite deaf to all conversation. H< 
means of comprehending what was spoken were derived froi 
watching the movements of the lips, and the sounds she uttert 
appeared to be the result of her attempts at imitating the movi 
ments she saw. Upon examination, having found that the voio 
was heard when spoken into the ears, I recommended countei 
irritation and the use of a long elastic tube. At first she coul 
hear only for from three to five minutes at a time. In a fortnigfc 
there was decided improvement in the hearing power, and she bogi 
to experience a painful sensation in the ears when too loudly spoke 
to. To use the words of her sister (who devoted herself to l" 
poor patient in a way that only a sister or parent could), " Dm 
the third week the improvement was wonderful. This waa not 4 
perceptible with the tube as in her hearing generally. Everythii^ 
was so much louder to her, but not more distinct. The noise i 
the street now quite annoyed her : she called it dreadful, althonj^ 
when we arrived in town, she did not notice it." She left mei 
the end of a mouth's treatment, and I directed her to be spoken I 
daily, but only in words of one syllable, which she was to r« 





AF AND DUMB. 



herself. Then very simple sentences were tried ; which she heard 
and understood when spoken to through the tube in the ordinary 
way of conversing, and replied by speaking through the tube her- 
self, 80 that she was able to hear her own voice and modulate it. 
Her sister writes: "In October, 1857, she spent three weeks at 

, and there she vas seen by people who saw her just before 

she came to consult jou : they said they should not have believed 
it possible for her to have improved so much in hearing and articu- 
lation; her miod, too, had come out so. During the three weeks 
she was from home, she had a complete holiday {t. e., the tube was 
not used), and when she came back, the hearing had not retrograded 
generally, but she did not hear so well through the tube. Since 
her return from a visit, she has gone steadily on with the use of the 
tube. Latterly," — this was written on February 2d, — " for some 
weeks, I have talked through the tube daily an hour divided into 
three or four intervals. Two or three times, when much amused, 
she bore its use, without fatigue, half an hour at a time, and she 
said she could have borne it longer. Even when she has had & 
difficulty in comprehending what was said, I have never allowed her 
once to see my lips while talking through the tube. We spelt the 
words which she could not make out, and she never once failed to 
find them out by the aid of the ear alone. One afternoon she could 
not understand a single word of sentences she had distinctly heard 
in the motning. By degrees, however, she made out a word here 
and there, and in a few minutes heard everything I said. She had 
been absorbed in writing a letter till a minute or so before the use 
of the tube. Several times now, I observed that she heard far 
more easily at the end of our talk than at the beginning. To her 
best ear I am obliged to talk in a high treble, not loud. The left 
ear requires a deeper, stronger voice. Great distinctness and slow- 
ness are necessary — a monotonous tone suits her best. The Jinal 
consonants must be strongly uttered. She says she now hears them, 
but she never did so before. She notices the difference of touch in 
persons playing on the piano, and can often understand much that 
is said without seeing the mouth. A few days since she esclaimed, 
' You are talking French.' Lately she has gained many new 
phrases, trying to apply those she hears in conversation, very often 
making wonderful mistakes. Not long ago she said, ' That tree is 
a great assortment for the birdd,' meaning ' resort for.' At another 
time she said, ' I hope you will not think me liberty,' meaning, ' I 



432 THE DISEASES OF THE EAR. 

hope you will not think I take a liberty.' She began to read half 
an hour a day ; it was hard work, although the book was written 
for a child. As hearing improved, articulation and intelligence 
improved, and lately I have often wondered at the change. We 
increased the reading to an hour, my sister constantly saying, ' I 
feel as if something were coming to my mind,' and expressing sur- 
prise that she could understand what she never could comprehend 
before. She now quite distinguished between my mode of pro- 
nouncing and her own, and we never had the tube while reading to 
her, as I knew its use would have distracted her thoughts from her 
book. Occasionally, when the word was a very difficnlt one, she 
made it out, and then had the tube used to convince her of her 
correctness. Numbers of people have remarked my sister's im- 
provement. A lady saw her the first time in the beginning of 
August last, and she saw her no more till November, when she said 
to me in astonishment, ' I could not understand a word your sister 
said in August ; now I can understand everything she says.' When 
I began your plans, I had to ask my sister, as a favor to myself, to 
allow me to talk to her sometimes ; she was annoyed, and then did 
not hear so well. Now, things are very difiFerent. She very often 
proposes the use of the tube, and says she wishes you could know 
what we had done for her." 

Another case, very similar to the above, also occurred to me lately. 

A young lady, jet. between twenty and thirty, like the case above 
cited, had never heard sounds so as to be able to speak or read with 
any degree of distinctness. I subjected her to a treatment similar 
to that pursued in the above ease, and the result was also satisfac- 
tory. In about four months I received the following report in a 
letter from her sister: "I do think she (the patient) is improving; 
a good many of her friends also think so.'* In another letter the 
same sister writes : " I really do think the improvement gradu- 
ally continues, although slowly, which perhaps is the best and 
surest." The patient herself writes : " I cannot tell how much I 
have improved in hearing, reading, and speaking ; but I now read 
much better, and I know the numbers very well by the tube. I 
hear everything continually. The G.'s, during ray visit there, and 
Aunt F., say my improvement is much in speaking ; they under- 
stand me very well, and I am very glad of it." 



ON THE DEAF AND DUMB. 488 



The right ear uselcMfor sixty years; at the age of seventy so greatly 
improved as to hear conversation all over the room, by means of a 
trumpet. 

I was called into the country in great haste in the spring of 1856, 
to see a nobleman, set. 70, who was suffering from an attack of in- 
tense inflammation of the mucous membrane lining the left tympanic 
cavity. At the time of my seeing the patient, the inflammation had 
extended internally as far as the labyrinth, and the power of hear- 
ing was destroyed. The only means of communication with my 
patient was by writing. Having but slight hope of doing anything 
towards the improvement of the hearing power of the left ear, I 
turned my attention to the right, the drum of which had, I found, 
been inflamed and damaged in early life. I proposed, amid opposi- 
tion at the supposed utter uselessness of the experiment, to try the 
effect of a loud voice spoken into the right ear. The result was 
decided, the sound of the voice was distinctly heard, and some 
words were understood. Feeling that the nervous system of this 
ear was lying torpid, from the circumstance that ordinary sonorous 
undulations had not been able to reach it through the diseased con- 
dition of the membrana tympani and mucous membrane of the tym- 
panum, and also from the weak state of the nerve itself, I determined 
to try a plan of treatment having a twofold object, — the excitement 
of the nervous apparatus of the ear by the healthy stimulus of 
sonorous vibrations, through the use of ear-trumpets, and an im- 
provement of the condition of the drum, as also of the mucous 
membrane of the tympanum, by remedial applications. The former 
of these objects was attempted at once with a most satisfactory re- 
sult, for the hearing power gradually increased. In short, by the 
means in question, the latter of the two being principally gentle 
counter-irritation, the patient's power of hearing in this ear, which 
had been so defective during sixty years that its faculty was con- 
sidered 'Most," became, in the course of eighteen months, so im- 
proved, that for a long time previous to his death, he could hear a 
voice speaking near to the ear, and with the aid of a trumpet on his 
table could carry on a conversation with persons sitting in different 
parts of an ordinary sized room. In this case I am confident that 

28 



4S4 THE DISEASES OF THE EAR. 

no good would have resulted from the treatment, if the nervous ap- 
paratus of the ear had not been stimulated at the same time by the 
influence of sounds ; and my experience tells me that hundreds of 
persons are living with one ear supposed to be perfectly deaf, and 
in reality useless, but which might be made very serviceable, were 
the sonorous undulations conveyed to it by artificial means. 



i 




CHAPTER XIX. 



EAEl-TRUMPETS AND THEIR USE. 



I 



In some cases of iliminishcd power of hearing, there can be no 
doubt that car-trumpets afford great assistance, and are a source of 
much comfort to the sufferers, On the other hand, if imprudently 
used, they aro apt to increase the deafness and to cause additional 
distress. They are decidedly injurious, for instance, in the early 
stages of deafness arising from debility of the nervous apparatus, 
and the noises are likely to be increased by their use ; while in the 
old standmg cases of the same disease they often prove moat service- 
able: they arc also equally advantageous in cases of partial anchy- 
losis of the stapes to the fenestra ovalis. 

Ear-trumpets may be considered under three different classes, 
according to their use, in as many degrees of deafness. 

The fir»t class consists of instruments to be worn on or in the 
ears, without the ai<l of the hand ; and by means of which more 
voices than one, or even general conversation, can be heard. 

The most useful of this class of instruments are the small cornets 
made by Mr. Rein, which are connected by a spring passing over 
the head, that serves also to hold them in the ears. The cornets 
can be concealed by the hair or worn under the bonnet. A variety 
of this class is a small cornet, which can equally be concealed by the 
hair, and which fits into the car, where It is retained by a convolu- 
tion which passes around the car and dispenses with the spring. 

The tecond class consists of instruments held In the hand, by 
means of which one voice, and sometimes more, spoken near the 
extremity, can be heard. 

To this class belong all the varieties of trumpet of different 
lengths and shapes, whether made of tin, gutta-percha, &c., and 
consisting of a narrow portion inserted into the ear, which gradually 



436 THE DISEASES OF THE EAR. 

expands into a wide mouth. These trumpets must be held in the 
hand, and the expanded portion can be directed to any person or 
persons whose voices are desired to be heard. 

The third class embraces a variety of elastic tubes, one end being 
placed in or on the patient's ear, and the other held in the hand of 
the speaker, whose mouth being applied near or in its free extremity, 
his single voice is heard. 



APPEl^DIX. 



LIST OP PUBLISHED PAPERS ON THE STRUCTURE, FUNCTIONS, 

AND DISEASES OF THE EAR. 

On the structure of the membrana tympani in the human ear. With 
numerous engravings. Philosophical Transactions, 1851. Part I. 

On the functions of the membrana tympani. Proceedings of the 
Royal Sodetxfy 1852. 

On the muscles which open the Eustachian tube. Proceedings of the 
Royal Society, 1853. 

On the mode in which sonorous undulations are conducted from the 
membrana tympani to the labyrinth, in the human ear. Pro- 
ceedings of the Royal Society, 1859. 

Pathological researches into the diseases of the ear. Medico-Chirur- 

gical Transactions, vol. xxiv, 1841. 
Pathological researches into the diseases of the ear. Second series. 

MedicO'Chirurgical Transactions, vol. xxvi, 1843. 
Pathological researches into the diseases of the ear. Third series. 

Medico-Chirurgical Transactions, vol. xxxii, 1849. 
Pathological researches into the diseases of the ear. Fourth series. 

MedicO'Chirurgical Transactions, vol. xxxiv, 1851. 
Pathological researches into the diseases of the ear. Fifth series. 

MedicO'Chirurgical Transactions, vol. xxxviii, 1855. 
Pathological researches into the diseases of the ear. Sixth series. 

MedicO'Chirurgical Transactions, vol. xxxviii, 1855. 
On the diagnosis of the condition of the Eustachian tube, by means 

of the otoscope, without the use of the catheter. Proceedings of 

the Royal Medical and Chirurgical Society. Medical Times 

and Q-azette, April 9, 1853. 



438 THE DISEASES OF THE EAR. 

The results of some inquiries respecting the deaf and dumb. Pro- 
ceedings of the Royal Medical and Ohirurgical Society. Medical 
Times and Gazette^ 1856. 

On anchylosis of the stapes to the fenestra ovalis (stapedio-vestibular 
articulation) associated with rheumatism and gout ; illustrated 
by more than one hundred dissections. Proceedings of the Rayal 
Medical and Ohirurgical Society^ 1858. 

A case of deaf-dumbness, of more than twenty years' duration, in 
which the hearing and the articulation were greatly benefited. 
Proceedings of the Roy al Medical and Ohirurgical Society ^ 1858. 

On the nature and treatment of those diseases of the ear which 
have hitherto been designated otorrhoea and otitis. Trans- 
actions of the Provincial Medical and Surgical Association^ 
vol. xviii. 

On osseous tumors growing from the walls of the meatus externus 
of the car, and on the enlargement of the walls themselves, 
with cases. Wood-cuts, Proceedings of the Provincial Medical 
and Surgical Association, The Journal of the Association^ 
1849. 

On the use of an artificial membrana tympani, in cases of perfora- 
tion or destruction of the organ. Proceedings of the Provincial 
Medical and Surgical Association, The Journal^ 1852. 

Disease of the tympanic cavity, causing caries of the bone and 
paralysis of the portio dura nerve. 

Osseous tumors developed from the parietes of the external auditory 
meatus. 

Disease of the external auditory meatus, with suppuration of the 
brain. 

Series of preparations, illustrative of the diseases of the membrana 
tympani. 

Bony stricture of the Eustachian tube. Transactions of the Patholo- 
gical Society of London, vol. i, 1849-1850. 

A series of cases, illustrating diseases in the cerebral cavity, origi- 
nating in affections of the auditory meatus. 
Neuroma of the auditory nerve. 
Molluscous tumors developed in the external auditory meatus. 



APPENDIX. 439 

The effects of molluscous tumors on the petrous bone, when de- 
veloped in the external auditory meatus. 

Preparatioos illustrative of hj-pertrophj iu the epidermoid and der- 
moid lamina of the membrana tympani. 

Caries of the petrous bone and abacesa of the cerebellum. Trans- 
actiona of the Palkologiaal Society, vol. ii, 1850-1851. 

Congenital malformation of the external ear and meatus on each aide. 

Calcareous matter in the cavity of the vestibule. 

Examination of the ears of a deaf and dumb child, in which a 
portion of one of the membranous semicircular canals was dis- 
tended with otoconie. 

Disease of the base of the brain, extending from the tympanum 
through the labyrinth. 

Necrosis of the squamous portion of the temporal bone, originating 
in catarrhal inflammation of the external meatus. 

Cholesterine in the mastoid cells. Transactions of the Pathological 
Societi/, vol. iii, 1851-1852. 

Case of ulceration of the fibrous laminie of the membrana tympani. 
Case of complete bony anchylosis of the stapes to the fenestra 

oval is. 
A case of perforate membrana tympani treated by the substitution 

of an artificial membrane. 
On the mode of dissecting the oar for pathological investigation. 
Neuroma of the auditory nerve. Trainactiona of the Pathological 

Society, vol. iv, 1852-1853. 

Caries of the temporal bone, and disease of the brain produced by 
retention of the discharge in the tympanum, after scarlet fever, 
by the thickened membrana tympani, 

Anchylosis of the stapes. 

Disease of the ear affecting the lateral sinus and cerebellum. 
Transactions of the Pathological Society, vol. v, 1853-1854. 

Encephaloid disease of the tympanic cavity, extending to the brain. 
Acute inflammation of the mastoid cells extending to the brain. 
On the causes of accumulations of cerumen in the meatus audito- 

rius externus, and their effects on different parts of the ear. 

Transactions of the Pathological Society, vol. vi, 1855-1856. 



440 



THE DISEA 



THE EAB. 



Dissection of a case of malformation in the cars of a om 

hurgh Monthly Journal of Meiiical Science, 1847. 
On the pathology and treatmeut of Ihe deafness attendant t 

age. Monthly Journal and Retroapeci of the Medical Seie 

Nos. 98 and 99, 1849. 
Case of stricture of the Eustachian tuhe, with an acconnt ( 

appearances presented on dissection. Monthly Journal 4 

Medical Science, 1850. 

On the tubular ear speculum. The Lancet, Oct. 1, 1850. 

On the removal of foreign bodies from the ear. Provincial Me4 

cal and Saryieal Journal, 1850. 
On the nature and treatment of poljrpi of the ear. Medical S 

and Gazette, 1852. 
On the excision of the tonsils and uvula in the tre&tuient of c 

ness. Medical Times and GrazeUe, 1858. 
On the removal of polypi from the ear by the lever-ring forceps a 

the dressing-ring forceps. Medical Times and Oazettr. 
On the functions of the muscles of the tympanum in the hutnan c 

British and Foreign Medico-Ckiriirgical Sevieie, 1853. 
On the use of an artificial memhrana tympani in cases of deafiK 

dependent upon perforation or destruction of the natural orgi 

Octavo. 1853. 
Do., do., Sixth Edition, 1858. 

A course of clinical lectures on the pathology and treatment of t 
affections of the ear causing disease in the brain or it« i 
branes, delivered at St. Mary's Hospital. With enffravim 
Medical Times and Gazette, 1855. 

A course of lectures on the nature and treatment of the dise<asea of J 
the ear, delivered at St. Mary's Hospital Medica] Sohoolt | 
Medical Timet and Gazette, 1856. 



A descriptive catalogue of preparations illustrative of the dueatei 1 

of the ear in the museum of the author. 8vo. 1857. 



TltE END. 




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ASHTON IT. J.l, 
SarguB to Ibe BJuktioi Dii|HDHr7, te. 

ON THE DISEASES, INJURIKS, AND MALFORMATIONS OP THB 



RECTUM AND ANUS; wiib 
.unckiD edilion Wall hands,. . _ . 
( »buul3O0p«eaii. iJujIIuiMl.) 

tttt-ClUnirgiGmt Rtpum. 



ID very beau i it u 11;^ priuled ui 






m^ebc 



"g)""«" 






ALLEN (J. 
THB PRACTICAL ANATOMIST; or 

ROOM. Wi(b 368 illBBtiBUODs. UioDebuid 
liier. US5. 



vliubJs nu; be the ' 



MJ, M. O,, 

BiyLvuua Medtcit Collige, &e. 

The Student's Guide iu the DisBeating* 

ime tojai llina. volume, at over 60O puge>, les- 



ANATOMICAL ATLAS. 
B; ProfesMTfl H. H. 8mith aad W. E. IIobnes. of the University of Peaasjl- 

*Mi«, IvuLSvo-.eXlracluib.Wiifa nearly 030 illii4ini><>i». O" iSw S.vicii, p. 331 

ABEL (F. A.), F.C. S. AND C, L. BLOXAM. 
HANDBOOK OP CHEMISTRY, Theoretical, PraL-tionl, and Teobnical; with a 

BflconuDenilnlory Pnimx by Ur, Hofmann. In une large u<.'t»vu volume, extra ciolti, of 6SS 
pages, vritn >llu.l«iion». « aS. 

ASHWELL (SAMUEL), M. D., 

ObiletricPhyiiclBninil Lecturer tJiQiiy'i Huipiul, Lnndnn. 

A PRACTICAL TKEATlSl!: ON THE DISEASES PECULIAR TO WOMEN. 

Kluairsied by Oa»cs denvi^d I'rum HoB|iitBl and Private Fraciice. Tbird Anieriuan, iron) ibe Tbird 
aad revued Londoo edilion. In one octavo voluoiD, extra dolh, of 6iS pagoa. (3 UO. 

the EcKliili lKa(i>.«E. — £»»■ Mid. and .:i'atc. ud praclieaJ, workou (cnnlediiieuiulbiil webiix 



ARNOTT (NEILLt, M.D. 
KLEMENT8 OF PHYSICS; or Nataral Philoaophy, General and Medical. 



BIRD (QOLOINQ), A. M., M. O., He. 
URINARY DEPOSITS: TUEIK DIAGNOSIS, PATHOLOGY, AND 

THERAPEUTICAL i,V 1)1 CATION 3, Edited by EoauHO LtrfiYD BiaasTr, M. D. A new 
Amer lean, Ironi the lillta aud eiilvrged Landnn edition. Willieigbiy iJlustraliuns oil wond. In oua 
faaadiKitne octavo volume, uf ajoul'tDU [uges, extra clolli. frjUU. (^<iM Uine-i.) 

The death of Dr. Bird hoj rendered it necessary lu enicuai tbe reri>irjn of Ibe prewiil edition to 

endeavored to carry out tbe auihor'ii plan by loiruduclng lucli new mailer aad modificalioni ol 
ine leii a* Ibe prugrftHi of rcicnca hai dalleij Tor. Notwilbslaudins ibe ulmoul caro to keep liiF 
work within ■ reasoiiBble compass, tbew addiiioni have reiuKtil in a coutiderable eolariptiiieut 
It u, Itterefore, buped ihal tl will be (bund I'ully up lo (he preieol aoadilioo of Ibe subiect, and that 
the repulilioD of tbe volume as a clear, cumpleLe, and cumpeiukjun manual, will be fully mainlaiued, 

BENNETT IJ. HUGHES), M. D., F. R. S. E., 

THB PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- 

IjOSIS, and on ibe Loual MeJicaliooof Pharyngeal and Laryiigeul UiseaaeB frequenliy misiakrn 
■ wilh, PbthuiiB. One vol. 8vo.,eiiraelu(h, with wood-cuw. pp.130. H 35. 



BAHLOW IGEOAOE H.), M. D. 
A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. 

g. Comhix, M. 1>., anlfaur of "A Practical TniHiisa on UiMawe of Children,'' 
Borne octavo volume, leather, ol over 6(X) pages. S'i 75. 



Iitions bj D. 
In one hand- 



an maaur ■> a uoil volttafrle vuila-uiucuiii. We Mh . 
fcavBhaJfraqBaai oeaarfaa IB euaialt it,»aJ >av»[ 



IclHI 



idStft }nr 



4 BLARCHARD fe LEA'S KEDICAl. 

BUDD (QEORGE), M. O., F. R. S., 

Profrwr of nsdieioe in Kim'! CalIe«B, UiBdna. 

ON DISEASES OF THE UVER. Third American, from tbe thirf i 

eiilorgcd Lundon editiiw. In one very handMime ociavo volunK. eltra ckHk, wilh (b«T h 

ruUy coIdriiI pJnleB, Bod numerous wood-ci 

Hii fkirlf ctlAbhih«d ToF iLirira place am an f^ the | ii Dot peracpLibtf Ghu]fr«df Uifl talitory of li' 

elalilenl mediMl liWriiliiM of Escbinil.— ilriliit eiiiki ii uurie i»r - ■ - ---■' ' 

«U niriifm Mtdict-Ckit. Bniiw. wllb the px^re 

Br. Budd'i TiHliR oa Dimw. of Iho Lliti ii T"'i'"'S'!"ii 
■uw > Uudnnlwark IB Madii»l lLle«tni«, ami dar- twdni «•<(. 71 

ncXilve edillnBa, tJ)f ■ 



Dinlns (BK^n. tl M Ikl V 









I Ihr dim 



>«i>r whiefa It tr 



iorlMd tb«r«BMlpr<iitBHof hepnlinphyilolify Ihe Inrncd nultior »iiilBii ia tht picKDl « 
piUialDiyiBolbalariliaiigliitieiure of the built i /Ih^Im ^MriifJir/nnM;. 



, M. D., .KB DANIEL H. TUKE, M. D., 

m Lunntic Atylani. VUiling Medical OlBcK In the Tor 

A MANUAL OF PSYCHOIX>GICAL MEDICINE; containing ihe Hist 

NoKxIogy, Def-ripiion. Slatlolica, DiiucnofiK, Palbolofr, uiil Trealmenl ol ISSAtilTX. ' 
a Plaie. In one bandrome dcibvu volume, of 53d pagea. S3 00. 
The increaw ol menial diwue in ila winus lornic, and the dilAcnll qoAlioi 
nontitnily Riving riw, render Ibe subject otie of dBily enhBDceil inlereM, requiring on the p. 
LephTTiciBn a oonalanllygreiler lainiliarily with Ihi!, Ihe inoBl perplexuig bruicli uF hit pi 



inglbe nsiiltKur noenl inve.'llgslionii in Ibe DiagnuBia and Fiiicnoi-i» uT Intanily, and the ^rcalif 
jmprared DMlbadE of inMmeat which havs done so much ia alleviaiiai the oondilkxi or loluruf 
Ibe health of Ihc inuoe. To fill lhi« vnocaoy Ihe publishers pre«nl this volnme, asanred IkU 
Ihe diillncuikbeil repuUlkm and exuerience oT the nnlhora will enlille il U onee lo the «Hi6d«nM 
of both ^luiWni and prai^lilioner. Ita trope may be sBlhered frum Ihe declBralinn of Ihe amban 
that ■ilheirnim has been lo nupply a ie»i hook which may Wf rve bh a giiid^ in Ihe ecquiHilika ol 



la leaching lo aiiffice (or Ibe d< 



I 



BENNETT (HENRY), M.D. 
A PRACTICAL TREATISE ON INFLAMMATION OP THB UTERUS, 

ITS CEKVIX AMD AFFBMDAUE8. and on ila conneolion wilh Uterine Uiwan;. To wbwk 
11^ added, s Review of ihe prewnl »lale of Uterine Pslhology. PiUh American, rram the XhUi 
English cdllion. In une octavo volume, of about SOO pages, eilt^ cloth, ti 00. 



BROWN (ISAAC BAKERl, 

BBrneim-Accnucbiu t In 6l. Mity'i Uixpiial, ke. 

ON 80MB DISEASES OF WOMEN ADMITTING OF eUBQICAL 

MENT. Witbhandaomeilluiir^lions. One vol. 8vo., eilra dolh, pp. 376. >1 00. 
addition to o^letrieal lilersliirB. The operaiiva J"''""""'^' """»'■• 



imeadlag it . __ 
ia*r»rpr— ' 



BOWMAN (JOHN E.l, M. D. 
PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Seoood 1 

rican,I>oiin Ihe third and revised English Ediiion. lu one ueal volume, loya I ISno^i 



INTRODUCTION TO PRACTICAL CHEMISTRY, INOLUDINO 

LV14ll^. Seound American, from the second and revtspd London edilwo- ^ 
tralionB. In one uual vol., royal ISmo.. eilra cloth. [^. 35U. »1 aS. 



:ale on the laws of health in re- 



TEOBTABLE LIPEj I 



illoinallaiia, pp 131. BO ce 



BUCKLKRONTHEKTIOLOQV.rATBOLbll 
AND TKEATMBMT OF PIHRO-BBONCS 
TIS AND RHEUMATIC PNBUMONU.j 
maBvo. viilunie,«ilnelath. pp. IH. VIM 

BLOOD AND UEUNE (MANtJALS ON]. J 
JOHN WILLIAM etlPPITS, O. 0# 
RKESE. AND ALPRKD MARKWICK. 

plaira. pp"S«it, "il M, '"""' "* '■ ' ■ ' 

' BRODIE'B CLINICAL IJ^CTTBEa C. _., 

SKKY. Ival.aro. alMt. aW|r^ JAi^fl 



AND SCIENTIFIC PUBLICATIONS. 5 

BUMSTEAD (FREEMAN J.) M. D., 

Uclurer on Tcacnul DiieUKi ■( lli>^ Collrgc of Pi.y»ci.i»and Sucitsoni, Now Ynrk, Me. 

IHE t'ATHOLOGY AND TREATMKNT OF VENEREAL DISEASES, 

incliiJinK ihn results uf recepl i n tow iga' ions iipuu Ihe nibjiirl. Wilh illnalraduni" on wood. In 
one very htndsame ocinvu volume, or De*r1y 700 lugta, extra dalb ; (3 73. (iVow Ramlf.) 



Br f>i lite mna Tilmhlg enmrltiDtioB to itiii nr- 
ttsaliT bniDFb of pneree Ibat liic icen tbi llg*il 

MM dcMilpIinii or ibe nrlntii (i 

diKiKE, antf eipcelall]' tha nclhud 

Mnpoas, ara worUjr flf tk* blgbai 

llwae MipMla il i> Muar ttfaiMKl >vr ui><w>i>uuii>b 

V Iha tnrj-diy pneiiUoMi tban U]r oib«r wlib 

Wbfeb WB an aaaualDted, la variagr ot mstboda 

.■n>p'>«Ml,iiiaiDiiEiincMntdineUD«,giiideilbre«re- 

iNI >liHriinlaiiil«i ot varying larrn* and fumplica- 

A* work wbl«b (bnald bclal*Bp«»enina<irBrery 
^^Uaaaiti^Cilaf Mtt. Jnnal. Mot. IHSl, 
._ TnafnregoiBgadiolrablBTnluinBcnnieBlooi.ain. 
'ktaciDR the whDlB anbii-El of ajmbil'iLuny, iciolrlaR 

'ltat«talDedi>|>^et«, BDd laouraillaiBtlnB Iha bail 
flOWpleMl) (vital noaofiiipb on ihMaBbitol in at 
i"— B^ilf AihratlheaKbor'iUbfiraiBfiuelVF 
MM<wBeiiMd,nr«l It ■ ilalT tu lay Itiat Aba 
'wt only axhaaaied bla aibjaei, bat b« bai pruaiuiux 
■0 m, wilhoDI tha illiktfai h)pe[1>nla> ili« bvil dl 

lie bu orried tti tiuratgn duwn to Ihe preain 
BOmenI, aDd baa iphi«nd bit laib In a nmniie 
Mleb BBBBnt bal rnlauDd In bla otgdit.— flrilul 
jDHHim Itunuit, Oct. KBI. 

Wt b<li«ve lliia IreallH will eome to b« ruiardiH 
Mbi^b aatbrntty la (bla litanchiirintdleiilpraBtiet 
Wia wc eordiatlir anmineBd li li. tbi> fmuiitablo nottsi 
lifouilireihiearHlbaprntijuloB, For unr ciwn (urt 
4ra candidlr eonrau ibal w« bare iMeiVed nani 



r. «, lesi. 

■be vhi.ls vork praianli • 
mraal ditMMi, oomprliittr 
inblr maierltl ihal h*i bsii 
I jonruli wHhlB tbe lut I:, 
i nt nuy aniwriaiBaM Hd in' 



CBtcflllly dlgHLflJ liy [lie bid uf 

Dffned lu tna nroroHlui Inia odmitililc rirm In 
coIDplslrDfiaUBeedFaa By Rood plain, wtiii^li iiia 
ERiBciallyrBtlJB tbsaBBlAmyof lfi«KMiUliiixani, 



tigwMl^Bfkikin Mid. J 



t impillsd tu Hif, M 

"•"■fflt'S"" 



pceuing DiicBBliillutioBwIlb thsfuU and ■Hraviaa- 
nuamDnner ia vrkieli ihsiubjHitbubaeaprBKnud, 

phrkaABOMT booane aL^rMttf pad, buttfbich tvobaio 
employ ia all aarlouanaai and aincvrliy^ wq du aol 

LI horeal^er bo ounai- 






BARCLAY (A. W.), M. D., 

AHlltant Phyiician lu 3t. Gootic'a HiiapilKl, As. 

A MANTTAL OF MEDICAL DIAGNOSIS; beine an Analjaia of the Signs 

■ad Symplume of DiMaee. Second American Troni the Kcond ami revised London edilion. • lo 
oorD>^Blix:luvovolume,exlraololb,Dfd31 pageaf 4223. {Novnady.) 

Thd demand for a aenond edition oribia wort »hnws Ibal Ibe vacancf which it allempls lo sup- 
ply ban been reoogn iieit hy Iho proretaion, and ibal tba cHbrM of the aiiibor to meet the want hare 
bean euccenfnl, Tba reviMon whieb il ban enjoyed Will render il bellcr Hh|it*d than before 10 
afford ufHiJilanoe lo the Imtner in the proiieciillnn ol biasluilirt, and lu Ibt: praolll loner whureqkiiiaB 
■ cooreniciii and acceaiiblii miinud forapredy refereote ia tho exi^nciea of hU daily duties. For 
tkia I alter purpote its complete and ex Icuaive Index renders it etpeciiilly valuable, oHecingl'auUille* 
Ah imiMHlialely turning lo any ulau of kymptonis, or any variety of dilate. 





ju-Jagan 


obaworbiaBBitberu 
Bii relay Iibb porfornmd 

Ibeorlali beliBowabli 


St. 


rail 




-jElwAM.S'j.imw'- 



Il Mtd Jnmat 



Wo hop 

™iiXBS?illm'!^Thoy'w'irne"^'r^«l" 
tulatDdyofitipageB.— CiiievHieriI.aiuil. 

Ad important (eqiiialllaB in nedieal Illei 
Ilia a work of blgbwiatfl, boiKfrua (be r> 
purunce of the aobjeel upon Wbish II trmi 
al« (lom Ibe real aolllty ditplayed in ')• si 



ao'ciebly dcieTTea-tkal pile.: In ev 



mdiii 



"!X,'S 



BARTLETT (ELI5HA), M. D. 
THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS 

Of THE UNITED STATES. A new and revised odilion. Uy Aui.tzo Clabk, M. D., i'rof. 
of Falhology and PrBViicnl Medidne m the N. Y. College of Fny^'iciuna and i^rgeons, tea. in 
--- octaTorolume,of BIX hundred pages, extra cloth. Price 13 CM. 

a woikorgmlpcaelicalnlaaudlalErHl, flood deatrvodlybigb sinoe ita Brat aBblicalloB. 
1 will bflMoaUiallthii* nuwreaobed itafoiuUii 



oikori>»( 

maeh that i 

r,le fully ■ 

oftbidile 

[o re ibl V poitra yed, ami 

fully uidaoou 



M^nii, with ih< ■ ■ ' 






. Tbed 



If fere 



teplulBly 



LWD, and to tl 
• mi.ce valuabla and a 
fever eitanl— 041a . 



foiuUi «Ii« 



tlamao 



""■;/' 



ipeiviiiiM of Prof. A. t; 

oalBalated lo avpceotau and discaaa 
Ihe msDv intricate aod dlltcull queitiOBa in patlia. 
logy, riia aiiaotollot.a.da mien lu Ln. inlercal of 

ll'mTf'tb.'ad^M aaTfMiil^al' Z^ra' ''°'""' 
UccwdWUias^ of i1la»ii>ii-*ai«tn«ifc/... 



BLANCU&EO k LEA'S MEDICAL 



CHKJirSTRY. In one bondsoine 3vo. volume of over 700 pugee. (Jutt Kea^ 

" Having been eogaml in Inching CtoemiBtry in lhi> MvUopoUf, llw uoo Tor ■ period oT iol 
Bndlho oilier for » pcriudol ihmy ymre, ii bDa uppeared lo uii llivi, to fuile i>rifae nuuilwr arboti 
alreKdyeiirliilK. Ibeh; wb- room Tor an addiliongl Toluine, whinfa tlitiiid be eupMiallr adapiedfl 
ilWlHoof •luJirors. In nrrpiiriug mub ■ volume lor Ihe pre»«, we have enileavorctl to beafj 
mind, ih>l 'he siu<leni in ihe prewnt day liv inucblo IsuD, bdiI liul a iliurl limeal hiadUpufal'l 
(lie aequitilluD iif lbi> learning." — Authob'i Pbetaoi. 

In reprinting lb l« vol II me, iivpaeKege itaruugb Die presa faaa he«n superiDlcndA] bv aocinpe 
KtusnUBl, who his wduloui-ly cndeavoied Ici recurs iho aociirarr' m neanMary in « work of it 
iialun:. Va notts or aildlitun* have been inlroducPd, bul Ibe piiblisbern bare In^n rorinvd l>yj| 
■iiiiiurc wilb KUme carreDliuiu and Fevitioun oTthtiSnllweuly-oaecbaplurB, wbicb bare be«D 4P 

Fur fulndi or mutter. Tor laBldity o( arraans- I Thiibnnk gim la iha clearFai and mitt 
c«l, D«.30, IMS. ' ' lohrml.lry.— Mid. n™.!, Noy.MI, ISW. 

BARWELL (RICHARD,) F- H,. C. S., 

A TRRATISE ON DISKASES OF TEIE JOINTS.' IltostnUed with ( 

iiuiB iin wood td anu veiy band&uiDe octavo volume, ol abuut SOU pages, extra clutk; 

|La(f/y IstHfU.t 

Al Ihe oolisl we nay itate thai the work la I to be or KiBBh Bie lo the prietlilDt lainiw 1 
wonh|r nCnaeb praln,Bn<l beara evideace uf niueli | may be in waBlulalreBtiHiiaaiieiaeaar»a|oi 
iliAaclittHi and earffiil imiiilry, and here and ititre ' and at tbe BnetlnteuDewhieli ennulu thaM 
«( BO illshl orlgioaliiy. We fia«e already »m<it | ianxmaitDii on anioulai atTHKuaa and tha on 

tetbeenientHievrorkdrirrTet. Wesanonlyafld, •"'• ' ' 

Edit Ihe peraaal of ii hai'atTnided aa great pleaiare. 
The aulhor hat evidently worked very hard al hii 
aohjeel, and hit iBVexlgaitont inio the PhyalolBgy 

naBBei whldi entillea bia In ba liitrned lowiih 
■inwlioB BSd Tcapm. WeniaatnDt omit In nHi- 
lins Ihe vary admlntbli plaiea with whleh ibe vo- 
lUBwlaeBrlehcil. We aeldom ineelwith luahilnk- 



This vol ame win bBwelcoined, both br Ibad 
taiili^iii ud iJio aiirgeno.M being Ibe ttvtt] 
nucli huoeit iciearrb and oaieful la reiltgatlw U 

he nalure and ireiilBiHt nt a biimi louorlai *^ 

if dieorderi. We caaaul enaelsde Ihlj ROt 
'alDBbleaBd nairal bootvrilhaal eaUluaK 

oUigBBmBliirtoiiajUsworkitcuBUlDa. „ 

irBaeBtdByafuBlniialiHMk-niahlBr.ltiBBOBlKn 
niter fnt a volume ID ahow UIhjiiobi lovntin- 
lau, and al ibeaaiDe tioia mifmsl thnogbi, oa IM 



WaoanB.ittahe leaiFO, howtTir, ofMr. Dan . ., ._._ , _.,_,. 

wilboui coDdralolmiBi hini nn the iniereitlnc liio luereiiial cnmpleli™ of hii ftrduosa 
aiDuHDl of tarurniatii'D whirh he has eiinjireiaeil Ltmrfeii Lnacii, MuishP, ItiDI. 



CARPENTER (WILLIAM B.}, M. D., F.H.8., Ac, - -■ 

EuBiiBsriBPhyilulDgyaDdCuiDparaUvcABBluDtyiDiheUalTerillj'or Luadoa. 

PRINCTI'LES OP HUMAN PHYSIOLOGY; with their chief ftppUeationa to 

Pijrrhulogy. Palholocy, TherapeuticH, Hysi«ae, and Forensic Medit4ne. A new Aaieriiwi, froa 
the iavi ond revlMHl London ediliuu. WnJAiearly three 'himdredilIu»lr«1ione. Edited, wit b atfdi- 
ilona, by Prhncib Citknev Smith, M.D., Prareetor uflhe ln«li lutes of Medicine in Ihe Pealtiyl- 
vaniaMedicBl College, dtc. In one very targe and bevulifuloelavuvolafue, of about nine hundred 
large page*, handsomely printed and elTongly bound in leather, with raised bands. $4 SS. 
For upwards uf thlrlem yenri Dt. Carpenlei's, Tuenloaile thlsf^reat work vn>aUbeBBM>rflaoa*. 

We ahourd ,*MrVB, n-iwever, ihal U ibia ediUM 

.. ...... I ^^ ^„,^_^ ^^ ^ 

inaek mailer of la- 



rally, bulk la U 



TBlDable cumpcndjuiin un ibe anbleci uf pkyiliilagi 
, Inmr language TliiidisllnrtiuBitowubilliehigl 

plltbedaulhor. ThepreieBtBdiiliiB(whieb,Ukr ibi 

»10,la"b^s™f'ofBB*eE'Mlenaivere'i*sk.n"lha'ui 
Bisy almual b« oiMUIderNl a Dew iwi>rk. We 
haralyBay^liieo(i«liidlBainiibriria"l)ce,lhai' 



DdniB who read II 



English laagaage. 



m«i?s'iire«U!! 

ny Of Ita defMt*. o/r ihey only appear w 



Tbo moil ooraplMC ekposillun of physiology whir 
— -<-- satMeni waieh we knowW in the E^lit 



ay onBGdniily reeMBnend ii at tha n 



1 Pkysio 



The moet cnmnleli 
l«ngnage.^jBi. ifad. 



bject — tiwfH lli4. Tim 

leie eyplopiedlB at Ihlt bivoeh of aelet 

Ud. iSni.. 

d'eaaloD of Ibis ooualrir. and perhipi i 



a 



Uanaa Phyatulug*. B>> ' 

™llljjta"ll Mr mMie^!". 
lion amoaa the prDTaaaiiii i 
BBvworklnaBydepanBiei.i 

BiiBDesaiOBl of liaappeainaae « 
pieaaare to every iiadeatoTFI 



AND SCIENTIFIC PUBLICATIONB. 
CARPENTER (WILLIAM S.>, M. D., F, R. 

THE MICROSCOPE AND ITS REVELATIONS. 

tauiing the Applicaiioi 
Illuilntedbyl^DUr'-- 



«r, S4 60. 



Dt. Cupenler 
Dinenlly iiubIlI 



loD u n micrutcopiiit sndphyBLutugi>>l,iuid hiH urefttexperieacs BRaleBcher, 

KoducH whnl has long boBJi wanted — agond leil-bimli on itw praeiifal 
Ibe prcvenl Volume his ublecl has been, a* Dialed in his PrelaoB, " la 
Oombioe, williia a muilerBle ouiDpagB. Ihal Inroriiialioii wiib regard lo llie u«c t>rhia 'loola.' whieh 
U moal euenlial lu IhB wurking micrMcopisI, with cuch an accuunl □( Ihe ubjeda ben fitit^ri fiir 
his ■ludy, as mighl qualiry him lo comprehend wh&t ha obMrves, snd migbl Ihi 
heaebi acieuce, whilst cipandinR and relVeBhiiig bisownmtiid " Thai be haii 
pti9binglhi>, no one aoquBinled wilb hia previuua libaraeaa doubl. 

The grcBl imparlance or the miciroEicope an a mean* ol' diagncwi*, and lbs i 
pisia who are ar>o pbyriciaiiM, have Induonl Ihe Anieriran |>ubli»herf , 
add an Appendii, f-arefully prejiared hy Pmfereor Smilb, on ibe appLi 
elinical medicine, lugelber with an account vf Americaii MicnMvnjm, lac 
aci^eDHirie". TinB portion of the work i> illualrated with neatly one hundred 
hoped, will adapi itae volume more particularly lo Ihe dk of Ihe American aladeat. 

Thnu who ace acqulDlcd with Dr. Carnentrr'a medical wolk.lbe additloai by Prof. Smith gira >l 
BrcvioBa writiogi on Amnial »uil VogrWl-lo VbyBlii- ■ pmUivc claim apns tha profuaiuo, (or wBich wo 

ledge ba li abls lo bring to bear vpna lo eumprehen- doM, we knmv aot where the iindeni or mBdicIna 
live a aablecl aa the reveUlioaa nf the nacriiMupe i will Gad aaeh a (oiiplBtB and uliifaatoT; B(ille«u<>li 
Bad eves Uoae who have bo pravloaa aeqaalatance of ■Bloroaeapie (heu bsaniig apoB pbTiiulagr acd 
' " ' llealnwdialneaaia eontaloed iB Prur.SalU'a 

adll; aarilhlsof llHir, ilaennitnga, la fully 



number or niloroKo- 
I aulhor'a approval, to 

lodiBcstitms and 



ELEMENTS [OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- 

LUOICaL anatomy, aeeond Americui, from a new md reviwd London edilioQ. With 
one hiindml and ninety ill aHlralions. In one very handsome ociavo valuing, leather, pp. 56Q. 

in publishing the llrtt edilion of this work, iln title waa altered from ihnt ot the Lumdon Volume, 
|w the '•ubr'iiiulion oftbe word " Blemenis' I'orihal of " Manual," and with the aulhor'a sanclioa 
the lille of " Elenwots" ia still retained as being inore eipresFive of the scope of 1h« trealJK. 

'-'-'—' tifeii™liF.icil^y,e«"'™doVlMrUi"n'oMi.ni 

tfaemKlveiofthenuualofVr.CariKiller ,— Mi^ii a I 



to the BBtbor^-KafafD HuUcal /evnwl. 

In hli roiBKrwurki it wouM Hem that I 
HfcsiialM Uie*ab|«elorPhraiuli«y. In the pi 
hegivei ilieri»ni^e,aa il wcie, urLbe whnla.- 



Phy.iol.«T, in ont 
laiBgB>ige-..^l. Lea 



PRINCIPLES OF OOMPAKATIVE PHYSIOLOGY. Now Amerioui, from. 

Ibe Fourth and Revised Loadou edhioa. In one large and handHome oclavu volume, wiita over 
tbree hundred beauliful illustralioos. pp. 752. Extra clutb, (4 80 ; leather, raised hands, IS Vi. 

■ * ■"* ' '" '"■""'• ■'".nf™i™""i5™' S^("'"lsi'uB''u'Dr°Ciitp'Bter"Yl req'liil^'fSr 
llaprodBellDBBphTalDloglst alOBcedeepfy read In 
Che libora ef otber^, npable of uking a geaerai. 



« buiieSlad Uereby. 



MMefallv to theyoBBfer Dlaaa would we eoidlally 
aemend It aa beat fitted of aajr work In the BBglish 
UagaagB to iTflBljfy them for the nHHOlloa lad cnin- 
prEheauoB o( those iTBiha which aie dai ly bung de- 

rdopediBphyilDlogy.— WerMtoICMnuiirir. 

Wlthnal pretsadiBg to il, It la bb eneyelofxdla oi 
lheaabieCt,B0C»ralBBIii1ci,oinlrl»iii.II r^neeu- 
a tmlhlal reSaoUun o( 
Inraat *f titiitti Bci 

AltalTmagBiBeMtv 
rtologleal itudy.— Jloa 



ived^iliitlvi QndrMrljr 



ta fellow. It la o 



Mpetfeai Idea of the rulaan at thia work, asd ai 
Idea gf its aaity, of Ihe admirable niBEnsr In whie. 
matecial baa taaaa broaght, fron the Boai vanna 
. 1 — toltaeompioMBeat.ofthalaeiil 

ptoreaaioB oaly, but the aeiCDIiBa world at largi 
mDBl Oel deeuly Indebted to Dr. Carpeaur for ihi 
■real work. It must, indted, sdd Itrgelyevea t 



! Iia high repautluo^it(M«al'nau(. 
I AUTBOR. {Frtpariag.) 

PEINCIPLKS OF GESEKAL PHYSIOLOGY, INCLDDING OBGANIO 

d illuslralious. 



A PRIZE ESSAY ON THE USE OP ALCOHOLIC LigUORS IN HEALTH 
ANU DISEASE. New ediiioD, wiiJi a Freface by D. F. Coki»k, M. D., ud a: ' 
'enUlc wwdi. J^ww wat iMao. Toi«— ^ tau* oloih. pp. ns. " 



BIjANOUAHO 4e LEA'8 HKDIGAb 



CON Die (D.F.), M. 0., &e. 
A PRACTICAX TREATISE ON THE DISEASES OF CHILDREN. 

edilion. revifiril unilHuginenled. In one Isige vallime. 8vu,, leslbcc, or crier 790 jAgBS. Ml 
(JiatUsuiii,l6:>9.) ■ 

la preMnllng n new Rn<) reviveiJ ediliim ol laiB ravoriia wurk. the publuh"" 
Ihnl the sulhor has Hndeavuivil lo render it In evsry mtpecl "aeomplEiir iii:i: 
Ibe pelholo{7 and ihenpeul'csoT ibe nmladiei) incideiit lo Ibe enrtier :m:<- 
■nd eisct aFcouiil oflhe di^ro'e? ol iiirancy and childbuod." To Bc^oni) : 
in* whole voik l« K ctrerul xnd ihamnfcb rcVMi«n. rewnrlnr b confMrnn' 

dwled faave been mppliFd. Ihal the rMenl lumr* of praiiilioner* and ob^rvi 
lOUghly inccrnirated.aod thai in every pDinl Ihewnrltwill be.faund tomnfntain the bwb nrpniaiiot 
" ' ■ '-■--- ' ■ — ' book of rercnmce iniufuulile afleelloaa. 










le and Ifaoroughly prui 
M editions are subjoini 



Jtiparfcla ■*• Auuriiam MtHcal AittiMUeu. 

Taken aa a whole, ia oar Indimnit.Dt. Cnndli 
TreatiH ia the nae rioni the peronlaf whirb I 
prae(ltiODerliitbl*couBtrywil]riaewitblliegTn 



'^y'favmlt} MUU 



work of Dr^Co"u?f 
—thtSmkiicort. 



—Okir KiMem a 



AnutieauMtiUaiJe 
inlhntili) thBiapeDtlf 



vniik OB Ihc 



•UBced thi Brai 

iKSHl or ' 

nolvlthati 



lananaie. and, noltrlthauading all thai baa ■( 
puhliihMl, wa ■till regard it in that lilht^-IMi 



nluforwnrkibynii 
arhich the phvaielan ii 
DappcedBtedbyalL; a 



rkorpr.l 



ula, and a aierBl work tai enaaBlOitHV, 
;aged la prMliee.— iT r, Mti. TtmmA 
the fngrIliedlll»D nf thi* dcaerVtKUi |X 
■a. Da rlw Ills isle- 1— ".-.— 

u been nb)«!t«4 u 

oihoti ud all Ml _.. 

iiaihuliigy aiiit (hrmpealica of cbitdian hata J| 






jitxi u 



Gurrence. — Btgalt J 



CHniSTISON (ROBER.T), M. D., V. P. R. S. E., Itc. 
A DISPENSATOKT; or, Commcntai; od the Phanniioopoeiaa of Orekt Bi 

and Ihu United Sialer: comphsiDg the Natural History, DeMiripiiuo, Chemistry, Phwn»^._ 
lion», VeeB, and Mortit of lie Arliolee ol' the Maieiia Hnlica. Second «tiiiUB, reri*ed«ad9 
pruved, with a Sapptemeiil conluning Ihe mo*l inipi>rliuil New It<ni«liei<. Whh eopioDf / 
tiling, and iwo hundred D»d Ihirleen lai^e wood-engiavings. By R. Eolesfbld GnirpiiB, I 
Inuiie very iBrge uad huud^ome ovtavo Tolume.lealhFr, raided bandx, or over 1000 p^e«. ( 

COOPER (BRANSBY BJ, F. R. S. 
LECTURES ON THE PRINCIPLES AND PRACTICE OP 8DB0ERX. 

In one very large ociavovnlune, extra oloth.or?!)!) pa^>. £3 00. 

COPLAND ON THE CAUSES, N*TU)tX,4 
TREATMENT OF PALSV AND APOPUK. 
In one vulane, royal IJno., extra elDlb- pp.1 



"ii wfoiii ™ w.^ 13 as'"' *' 

COUPEH ON THE ANATOMY AND AISHAftES 
OF THE BREABT, wiiB twenir-flve Miaullane- 
OBI ud Sarileu) Paprn One (arn n>lame, im- 
peiiaJ Sw., extra clolh, wub UST Igarei, nn W 
platea. BIF" 



EASES OF THE THfTIB, 



'RITCTUKE AND Dia- 



Wiii. 



CLYMER ON FEVF.RBl ' 



COl^MBAT DE L'lSEHR ON TlfE DISKAI 

OF FEMALKB. .ud uB O.^ .p.ei.l HF(i. 
ilad, with nuuijr Nntta at 



D Mll», M D. 9ee«HI • 
iprnved l« ""Lljy "^' 



CARSON (JOSEPH), M. O,, 

ProreanrafMaMriaMedluandPhennMvrialheUiiiTstiilyorPBaBtTlnwB. 

SYNOPSIS OF Til E COURSE OF LEC'J URES ON MATERIA H£Dld 

AND PUARMACV, delivered m Ihe LJntverKiiy 01 PenDeyljaDM Sroood Md !■! km\ m 
tioa. In one very nealuotavo volume, extra ulolh, ■>! SUbpi^i, $1 30. 



CURLINQ (T. B.J, F. R. S., 
A PRACTICAL TREATISE ON DISEASES Ot' THE TESTIS, SPBRMJt 

TIC CURD, ANLI 6CKUTCM Suooud Amenean, Iri'iii Hit Kcund audenlarfcd Euftithedl- 

' *,«W"^i|wlt>wUhnuau»f»Wf|lj))Wwl»"'i-J Bu i< > l».i S# 



AND SCiKNTIPIC PUBLICATIONS. 7^ 

CHURCHILL (FLEETWOOD), M. D., M. R. I. A. 
ON THE THEORY AND PRACTICE OF MtDWTFERY. *new AmeriDan 

from Ihc rourlh reviwd and enlnrged Lr>»d(>n edilioii. With Notes and Addltiuue, by U. fiK.ictB 
Uo.intK, M. D.. «u'hc)t ol ■ "PrnclieulTrealiBe on Ihc 'UiseuMs of Children, " itc. Wiih 1(H 
iUiip.intiimii' In one very handsomB oQtavo TolmoB, lenlher, of DMrly 700 large pages. J3 50, 
{JiutbnuJ.) _ 

Thii worlf has been to long an ettabliiibed favxirire, bulh as n lext-book lor lbs learner and as a 
Kllable aid in mn*ultai>on larthe praCLil loner, IbM in prewnlinga now cJllion ll is aiily aoce»wrv 
10 call allenlJDii lolke verj' exlendnJ t[n|>rovemenls wlikh II ha* recelveU. HnvinEr hud llie benefit 
W iwu reviKioil* by Ibe aulfaorfuice Ihe lail Amnricaa repriat, It hax been miueriiiUy enlarRed, sad 
fQ*. Cburchlll'a well-knawn cflnscienlliias indii»lry i< a jruirBiiteo Ihal every portion baa lie«n iho' 
Vmifhly braiighl np wllb the leieil reiulii of Guropenn laViMTifalian in all dupartmeult of iba sci- 

-»d art or □fai'ielrfcs. Tbe reeenl dale of Ihe last Dnblln ediliun has not lef) much ol novahy 

Amenota nltlor lo inlToduo^ bul he has endeaTored lu )n«ert whalevir has cince appeared, 
wiih »iich mallen v* his euerience has rhawn biin Would be detlrable fur the Amerioan 
iocludtag a lartre number of i I 111 si rations. Wiih tbe sancliun »r Iha auLliar be haa oildsd 
rm of au appendix, some chaplers from a Utile -'Mniiual for Mid wive- and Nurses," re- 
-ued by Dr. Churchill, beliavinE ihal the details there prefunMri can lurdly lailloprDre of 
ivonisni 10 the junior piBClllioner. The result of oil tliese additioBS is Ihul the vraik nuw oon- 

«ins AlTly one-half more mailer than the laal Amerloan editioiL, wiih niHirly uDS-half moni tliiu- 
ilians, M> Ibat antwilbatanding the use of a unaller type, the vulume oualauu alinmit iwofaundred 

No eflorl has been spared to Borure an imprnremeint In the raechnnioal execution of Ihe Work 
aqiial to that wbiob the led has received, and ihe ralume is eonfidenily preMnied as one of Ihs 
kand*amcFl ihal bas ihus &r been laid before tba American professiani while Ihe rery low price 
oSi-red should secure for it a place la eirery lecture-rooni and on every office lable. 

irerycveiusueil 
laftfid./eiinwl. 

nLuJ-WuUn 

nnrs useful *M 



Mvclenl, 
-k Ihe (<i 



■aro i>r it is fait nf iastractioa ; Ihf opinion of sil 
Riura oraathorilT is livcn an qaesliDiis of dlffi- 
pllv, as well *a tba direeUoas aad adncs at tbi 
iraad aotaoi hi oseir, lo which bs adds the rssalt 
statistical inqalrr.Dalclngstailslits in their DID 
rptaee aiuleliriBg then their due w*ighl,«»iil ao 
»•. We hare never read ■ bnuk nore free fron 
el jalOBey Was Dr.Oharcaill'a. II ap- 
1 ..., [j„ irteiisiiiga of a booh cm 

balb Iheoielically and prsc- 

• b4fie*es will bMeBt RKdleal (siinee, and insare 
MaAnyofthe^llcBt. W« have aald eioach to 
piver lo tha pieABslan that this book of t>r. Cnnr- 
illl's laadmtrablT 'Olted for a bunt at rerereace 
H the praalllioaer, as well aa a lut-bnoli for Ike 
ati<l<at, aad we hitpe It may be eiMKlTely pur- 
Aased amoiist our readers. To iben we mnai 
iMTeBfty ireopsaaaa II DMlin KtOial Prui, 

Juesa, teoo. 



AoBihl worthy o( a ravorable reeepllon by ilie 
Mjealpnblio, weeaDCDBlliIeBtlYaarni that this 

lie iIBdeat, nniT all ' 
■ - . theft 



Wiawifery. — Prtvimctal ATidfeai 

No wuik hold I 
s"Bin« of iKing 




:^pLmt\^'T.^°M,7i^\ 



PreriDesedltioat, nsdei the editorial sapervlatiia 
of Piof K. M. Busluo, have beep renelved with 

printed fraro every late Dahlia edltioa, esterully 
renssd and hrc-erht ap by the adthnr lo Che trreseat 
tiipe,dnes present an anus Ball y eecuTaLe en<l able 

fn the departneat of midwife ry. • ■ The e°l« 'nr», 
dlrHtaesB, and preeiaion of its leeehingi, ingFiher 
wiCbthagrcalaiaosntorBliUistloal twarcb whieh 

inV of works in this departmenl i/rt- 
.~ir. O. UhI. anid aUwf. Joanul. 



I ON THE DT8EA8B8 OP INPANfTS AND CHILDREN. Second Amcrioan 

' lorged by tha author- Edilod, with Noies, by W. V. KB*TiBa, M. I>. In 

9 volume, eilru cloth, of over 700 pagea. *3 00, or in loatber, S3 39. 

In preparing thih work a second time for the Amerima profession, the author has spared no 
labor in giving U a very thorough revision, introducing several newebnpters, apd rewriting olhen, 
whllecvery portion of the volume fans been subjected ton eevfre scrminy. Tbe eflbrw of the 
AsHincan editor have been directed in supplying mob infonnalion relative to mailers peeuliaf 

(brdi be safely pronounced one of Ihe most complele works on the «ubjeot accessible lo the Ame- 
rican Profession. By an alteralion in Ihe siie of Ihe page, Ihefo very exlensive additioua have 

BS8ATS ON THE PUERPERAL FEVERrAND OTHER DISEASES PR. 

CtTLIAR TO WOMEN. Selerledfrom the writingiolBritish Author* previtrasloXtW c\a*««V 
(keEighlcenlhCenlur)', In uotruealDClavo roJuioe, extra clotli,aI about 4S0 pKg«. U tA. 



BLANCHARD ft LEA'S MEUIOAL 



CHURCHILL (FLEETWOODI, M. D., M. R. I. A., &e. 
ON THE DISEASES OP WOMEN; including those of Pregnmcy uid CMM. 

bed. A uew ACierioun editiun, revieed by the Aiilhor. With NuUb ood AddilioDB, by D Fmjm- 
cisConslE, M.D., auifaar ol "A Practical Treauae on Ihe Uitca.-wa(irChiLilreii." Witli nuae- 
roUB iltustralioDS. In one large andhondsaiiM octavo voIuiiia,lealliet, of 768 potcm. t3 00. 
Thii edilim ol Dr. Churchill'i very (wpDlar Ircaliw may almosl be termed k uew wort, ■ 
thoroii^bly ha* he rKvieed il in every porliod. Il will be luund gre&Uy enlar^d, tod ootBplM 
broughl up to Ibe mo^I rerenl eondiliun ol the lubjetil, while the very baodbume tcix* of iQuM 
lion> IrtrodDMd, representiug tuch patbulugical conditioDs as can be aocursiely ixirlrayed, f 
a novel fealure, nnd afford vaLuable aMieiani^e to the yuiing p^aclilioner. 3uch uldiliua* _ _ 
peared deBlrable liir the American pludeni faave been made by the editor, Dr. Condie. Wta^ 

U-J I !_ ... L __=__. . ^ p^^ ^^^ l^gfj,.. .;_ .11 .,1 1 

iBbeenl- -■ " -"■ 



ompilaea, anqueilloiiiibif , o 
nf nedlecllunvrtHlgeln rei| 



!■ work la Ihe n<»l rollsble whlih « 
illiabieel; and iiifr»rvedlF popnlni 
inDDB.— CAarlfilim Mt4. Jeutimt,]ai 






itAi.CtaBrehilldoH. 



Hia, Indeed, U 



Ai ■ eoinptclimaive .fDUBuKl foe ttuileou, «L 
thsltriiiih pr«H HhUIh Qwarr. /iima^. 



uid rruiilee* ipeculati 



ir ol»^r%rv 



iiTsnieol Ameiii 



DICKSON IS. H.), M.D., 
Pn>f»i»r »r FracilFB or Mi>dieinr la the Jrlfraoa Medical Unllcge, PhiladelplilL 

ELEMENTS OF MEDICINE; i, Ctunpendious View of Patliology mad Th«i»- 

Cmie», or the Hinlory andTrpaimentof Diaeaaos. Second edition, revited. lu one large nd 
iidBome ocl«vn votiime ol IfiO pugais lenrber. S3 7S. {Jiul luiud.) 
The stead? ileiu and whwh haiwi soon tuihaugled Ihv finl edition uf Ihtt work, ■ulficimlly *h(i«i 
thai Ihe author waa nol miBtsken in >uppo<ing tbit a volume or this character wait needed — u 
eletiieniary manual of praoioe, which ■hould praaenl the leading principles o( medicine Wilh Ihe 
DMi^lioal resultB, in a condensed and peripicuous miuiner. Disencumbered or uuncceuary detail 
, il embodiea what ia moel requisile for the alndenl to lauire, and M ihe 
.... 'e practitioner wan 11 wben obliged, m ihe daily call* ol' hi* prol^uui, io 
rerreth hi* memory un apenial puinia. The clear and alliaclive aiyle or the aaibur reinlir? The 
whole eaiy or oomprehenairai, while hi* lone experience given to hi* teaching* no ai 
where aofcnowiedged. Few pbyaiciana. indeed, have had wider opporiuniii ' 
experience, and lew, perhapa, have ated Ibem to belter purpOHi. A> Ihe r 
vmed to stody and praciiw. the prei>enl edition, revised and broughl up lo ihe dale cf pitli^ii- 

will doubilens inamtain ihe repniaiion already noquirad a» a coudeu • ' — ' '- — * — 

text-book on the Practice of Medicine. 

DRUITT (ROBERT), M.R.C.S., Jbc. 
THE PRINCIPLES AND PBACTICE OP MODERN SURGBRT. 

\ and revised American Troin the eigblh enlarged and improved Lundiin •diiiun. IllimraMd « 
fViur hundrsd and thirly-lwo wi>od-enKravia|ii>. In one veryb&odiiomelyprinledM 

, leather, of nearly 700 large pages. S3 SO. fJuit haitd.) 

' A work which like Druitt'b SuROKev has foi sominf year* mmniBined Ihe po*iiioD ofn 

fng favorite wilh all clasaeE of the prolE**ian. need* nu rpecial recomniendalitiu to altravl oltei 

lu a revised ediiioa, Il is only neceaEary lo alaie Ibal Ihe aullior hu* ipnred nu paiua Iv keep ibi 
work lip lo ilB well earned repulalion of preMsnling in a amall and uinvaniiul uvnipau the UteM 
eondilioa of every deparlmem ol anrgery, conitidered both a>a acienee ud wan an; and ibal Ih* 
aerviceaoTa oompelenl American editor have been employed lo iniroduee whatever aovrliiwBH 
have eacaped Ihe author'* alieuliun, or may prove of eervicB lo Ibe American praMilkmer. . 
MVeral editions have a^qieared in London aitice ibe utat oS the lasi Amerlran r«pr!n(, Ibe tt" 

hoaliad t be benefit of n; pealed tevi^ionn by Ibe author, resulting in a very Inorvugta - '- 

improvement. The extent of there iddiliona may be estimated from ibe f»oi Ibal il 

abuut onethird more matter than the previo'u* American ediliiin, and fb*l nolwfl 

adoption or a finalier type, Ibe page* have been increaaed by about one hundred, while anirlf M 



id £Jly wood-cut^ 
A marked ioiprovemcnl « 
-- 'iich, prinisd in the 



'e been added to 1 he 
Blao be perceived u 



Tolunies aooeasiOl 
Thii popular 



d line paper, leave 






^licol axBOUtioa of lb* 
liiile lo be d<«ired a* 
d one of llw rti»f I 



[mprDTSBima.aiidaddi[i»n*,aBdili«pnncipl(iaDd 
Ilia pracllce uf Die art have bean bruaghl iIuwb ui 

InaaimrylilaiiopcsaaiPleioipeiklDobigliiT. The 

) aetnraie asd nnn"""*- ">■' "h' ■iu«i™i 
ID dlfieulij, witk 



olhlng if real praaiieal inpintanaa 

' Burgf TV up to Ihe preacai hoar. 




AMD SCIENTIFIC PUBLICATIONS. 



DALTON, jn. (J. C), M. D. 

mtrmvi <•( PhyiMoKj in rh* Cnlicge of PkriiDlini, New Ynrk, 

A TREATISE ON HUMAN PHYSIOLOGY, designed for tbe use of Stmlents 

I bihI PndilioDcr* o( Medwine. Sscoad rJltion, reviMd and enlar^l, wilb iwu )tii'>dred tuid 
KVeDly-oiw ilJuMriiiuuB un wood. In odc very beaiiiirul odavo voluoie, nf 100 piget, eitra 
clulb, ti UO ; lutaer, ralKd bandi, S4 SO. {Jiat limfJ, i661.) 

Tbe general favor whiRh bt* f n iiian exhouiled an FdiliDD oT ihii wnrk hat afliinled Ihe auihni 
an otiiii>rluni(y in ua rrviiiiun of supplying Ibe delicicncici wtiich uiiUed in ihe liirmer vkIuhif. 
;7his BIB pauwd ibe interlun of two new ckiplrm—ooe no Ihe Special iii!iu«>, Uib olber on lin- 
' bibitlAn, EilmlBtion, and Ibe Punciioot of ihe Lymphatic Syitem— beiide* uumeniUft ■iWliun* iif 
'MnallHr aRimiDl pratlerrd Ibroiigh Ihe work, Rnd * general revision digol^neJ In bring' il lliiirunuhly 
•■p 10 Ike praient ooadtlian of tbe acleace wilh rr^ard to all pnlnit wniob may be cuutlderpd a« 
^definitely Feitted. A DUDlbef ofnew ill unlnit ion* bus been introdured, and ibe Work, ill* boprd, 
•in its impruTiid (iirtn, may oualiuue to coromHud the eontidenoe ot Ibose fat whoK ime U is n- 



e, Ihnt Dr. DdIiob'i 



r riiH aipnliiiiiaU, tnfiollie' 



'4«rei'whiabclianeieri»*>>areniaindcrur Ilia Tol-i«it<iiieaB«<Hity, and it wUl B» dcabi In aTO 
-ifins, aad icndti ii by far Ibe moit deetcable Irxl- nuirs cuerly toiubt for tkal Me int. Thai it M 
•nok KB pkyniologT to place \o Ihe kuuli nf Ike not merely • reprisl, will be leu rrom the aiilkor.'B ' 



. ...ins* wiiieb be bit nads, fke (krcseai, lin 
Irit tilitlii*, ia prmie^ lb the l|l||lie(t iiyle nf iba 



*«>« EagiHh lingaaEi, or perbnpi In «nyi- 

■Herrfofo haie no lio«l«(i™ in rewmnMBding Dr .... ,.„ ... . 

4keii u>e Iben war "'her wuf k of the kiotl Hi whieh tbeir author lnlea<lr<l.— lt»fM JUi4ie<iI wid Surf 
.(bry hixE mr<:e.t.—Amtiuiim Jtunal of \U M'd. ' caJ Jtnmal, Maieh », tMI. 

4- It U, Iberefore, no diitwriKemnt to the naBy , eiifflee il loHy.ibil theyereBumtiaaiuiI Impmt^ 
Jk»ok««|MiBj»yainl<isy,ni<»iuieellnliD tbelrdar, i bbc, aad anoh aa will render Un wnra itill nura 
^•ayikaiDaliuB'auilieoiilynneihaialvuuiha vatBaDlaaadacerptabEatoUfearureaiiaaiHaleaia- 



spreheBdTe bat H 
•hed b 

nn^TVnw it ia 



I of the f eltinc np of the Hri t editii 
letylodTthB illnetralluBi i--- 
Lhla. No- 

. inllielinB _. 

. I Smrfiial Joarui, M>y, ISOI. 
The.ead<liiiOB>,whao 



III (en-book wiIboBla rirel, for tknu who „j (adoilry of IheaBtbor, reojirthebmil eieM.l- 
__.r«iniI«dypbyalolofii«t koitBee m i( ia kBtnni | u^ij. „^,f „ ,„, „„., enmpiate Mpn»* ..f a mi- 
ibiU moal laeaBiafBl ealtlVBtoi*. And ti iaphyal- i ^', „! whiob Dr. DaltuB 1* doBbDex the ahleal 

•l%lpalholagicalksovled>ei andftl.tM tara t. 1 3!rtoSw'M.<("T^'., fluy.'iaill. * "°~ 

tpebaaiinf ratiaflallkenpealici; BotbalpathiliH . _. ,,.. , ., , , ., 

^ . - - -' .' . "^p .. A Henna edllinn of thiadeeerredly pnpalur witrk 






mper dlHnane of onr ""ry-day 

- Dr. Dalian needa no word of ptaiae from sa. Ha ' eumplelely Cuilllled hia dcaign of preaEiiiing I" iJie 
jUaBlvsiwIly reengDiiea aaamuBf ths Brat, if not profraiinDB reliable aiiij prccile iexI bnnJi.auduBa 
*^ r*8iat,i.fAinerioanphy«iHlcifialaoow living, [ whiih weooBaider the beat oellin- ~- ■'■ ' — ' 



DUNGLISON, FORBES, TWEEOIE, AND CONOLLY. 
l*tHE 0YCLOP.^DIA OF PKACTICAL MEDICDTB: oomprising Treatises on 

L^ tbeNalnre andTrGBIiDeiil ofUiBeaivtiMBteriii Medica, and TherapeuliUB, DiReui^s of WomcD 

( a and Children, Medical Juri*prudenc<, Ice. ko. Id four large #upcr-royBl octavo Tolumea, of 

SSM double-columned pegee, strongly and bHadgomeiy bound, with raiVed band*. S12 00, 

*a* This worlcconieins no lei* Ibnn lout hundred nndeighlaen dlatincl irealwea, cootribuled by 

■bty-eighl diatiognifihed phyeiciani-, rendering il a c«mplels library of refennee fbr the eountry 

practiliuiier. 

Tbe niiat camplolo work on PmrtlMl Medlcins Theediturian pracliUonuaof calabliihrd repn- 

HUDl; or, at feMt, lo uur laagBage.— BuJala .tstLuo.and the liai o( eiincribBlDnembraeei muBy 

■ddtial Md Siircical Jaumttt. I of the nna t emiboi t srofcuoia and teaehera uf |;.ub. 

,, . . ]doD.EdiBbutgh, Dublin, and Qlaagow. 111., iB- 

For reftrenee, il ieabo»oall pnee to every prae- deed, [be great iBeritoi Ihie work that Iheprineipel 

tilioBcr.— H'aiurKl.iucii. artlclea bBTobeeB fumlihed by proctitioBera wBo 



•n .To-rul tj *f>d>t< 



aegonloianee HItb II 



lodera Engliah medicine » eihihlt^ Ib the moai 'thnrniwa dnetrlBeawil] hlghaBd'loataathorlty 

' • -V lighl^Jfadieol £zani»r. . i Amtrii^mMidiittJnn*!. 



OewBBB'B COHPREHGNSIVT! BY8TEM C 
MIDWIPKRY. Itlniliated by ocnaiuBBl eu 
BBd masy engraTiBga, TwelflB edilina, with I 



13 8L,AN0HARU « LBA'S MEUICAL 

DUNQLISON (ROBLEY), M. D.. 

Piofoitoi of In.iimw. of MHicino in Ihe I'Brnnn Msdioal Collfje, PUltadelphl*. 
HEW AND EtNLAROED EDITION. 

MEDICAL LEXICON; a DiotioDary of Medical Soienoe, ooDtsiniag m. e 

Eiplnnilinn ofihe TBrloui> Subjecls and Terms of Analiimir, PbyKioltwy, Pilbolo^, I-' 
Therapeuiirs. Phsrin neology, Pharaiacy. Surgery, Obsieiricn, Mmipb! Juri'prndeBCe, Den 
Sra. NolicMorClimdeaiiilDf MineralWaieri; PormutiB Tor OlSciiiBl, Empirical, aikd LI 
Prcpnra[ion«, &<:. Wiih French and olber SyDonymefi. Revised and very ^really a ' 
111 one very large and bandi^nnie oclavo votiune, of 9R3 double-coloaned pages, ia el 
Ilrongly boond In leadier, orilli raiaed banda. Price ti 00. 

Efpecial care bi 
wonby a continuance of ibe 
aale of FcrmiH large edilioni 
tbe profesMon aa the flandnrd I . ^ . .. . 

Creaeni revi«iOB to inlrodiKe wbatever mishl be aecsBaary 
le— ifnolindiapanaablB— Imticon, in wbich ibe atudrat may 
every lerni Ihal bat been tr^tiinBled in Iha nomenrlalure of I 
large additTon« have boen found reqninita, and Ibe extent of Iha 
from the fact that about BiiL Thopsimd aubjact* and lerma bavi 
\g the wbole number of dptinlllons about Siktt THOtriAND, 



derrag tf 
ber<.rp 



The medical press, bcMb in thia country and in England, ha* pronounoed Ibe i«. 
di-peiisable to all medical at udeuta ud praaliliuuera,a4id tbe piUMUt improved editin) Will m 
Ibal enviable repulMinn. 

Tbe publiBberii liave endeavored to render Ihe mechanioel exeenlion worthy ol 
■■'- ' in doily reference. Tbeg-rer* — ' '■— ■ ■— ■■ •- -'■— — 



■ccuraoy to neoearary i 



a work of Ihe kind. 



of labor uii ervdillM fn atedleal literttHii, One 
WrtHltllianll)' iBppOie adai couiaiit aac of tbe pre- 

Bcding edltiona, where we have aaver railed to End 
■ nfflatniltynitlMplawiliuaarsver) neiltnl um, 



and mrttLfumpretiftoaiveWorlcDf the kiadwhioh 
ever tpft^iei—Smffala Uti.Jvutm., Jan. ISU. 

The work i) ■ mnnnaieDt ot piUent reKareb, 
ikilful ladRmeal, and vut pliyalcal litHir, that will 
ncrpeluate the Dane nf lbs totbor mnre eObftnally 

AnngllanndeaeiTeathe iliankinei only of ihe Anie- 
rleim profeailun. hat of cne whole medical world.— 
Van* Am. Mtiita-Ckif. RevUta, Jan. 18C8. 
A MediBtli DiotloaKy belter adaptiul for 



eruiiuton diBplayed, apd ihs extranrdlnary indual'y 
which laUBl tiave hrea demasded, In III prepamtion 
and pr rrrmkn, redound to the laatlag era^t of iti 
amhnr.and have fa m [eked '■"■ - — " ' "' 

tbeaeelTci ■> ■£<■>■ wldi the hiclieel aiuid.ri 
nedSeal <n rnmu Hon.— S sum Milfoil wd Bur, 

Good lezicani and racyGlngMidl 
li enmetbing appalling to conleraplate. Ttio luthc 




AHU SCIENTIFIC PUBLICATIONS. 

DUNQLISON inOBLEVI, M.D., 
PnTunr of iBiiitum nf Medlivine in Ihc IrBrTK^ Medici,! CoIIfci, PhiUfclpbm. 

iHTTMAN PHYSIOLOGY. Eiglith edition. Thoroughly revised and erton- 

■ive)y duhIiAmI ud enlnrg^, wi(h five hundred uid Iliirty-iwu lilu^irolioas. Id two Urge and 
• InndMHUely fHnMd oclaTO Tolumeii, Iraiher, of abciui ISOOpogei. tTOO. 

tn revising idaworlE lor ils eighlh BpppBrsare, the Kriihor h» «piml no labor 1o render ii worthy 
■ cwnlinuuicx of Ike TCrygreal IBVOI whicb has been eileuili»l to il by the prol'eMion. The whule 
'•aolonlf hare beoD rorrmnged, uid la a f^real eilent re mode tied ; Ite iaveillgMiims which of late 
^mr* have been >o iiumeioue and ^ ituparianl, iurt beeu careCuliy esamiiied and incarpjralod. 



,'ud the 

li^'iSyof 



fM no foriner Bdiiiod haathe >i 

• WcbrilMslluitflematralTbeviid, 



. „... , . lib the preiHinl 

reader il a coiici*e but euiuprcheasive [realise, 

., . ..„ .to which Uie aludent and mui ofMienw san Bi . . 

Inty oT flQdlOg whatever Ihey are in Ktnrch of, fully preMDieil in ftll iu aipecuj and 



gs_«tll<mm'i Jh< 



cr.v: 



Tt ■! deaujiiliua and Ihat fHcility 
Htloo wMtfi TFDdar him pivniiarly 



LS Esfliab laii(u»ge — Aintr. I 



i« H work Bpan^phyiioJogy pTooeri la* « 
.be. f iiietiniii pBrTnr mndbTlliBhDdr.lluiila 



, and woiihy of ■ plass In B»«ry pbjr- 



«T THE EAHK jkltTBOS. {A new cdlftOB.) 

QENERAL THBEAPEUTICa AND MATERIA MEDIQA; adapted for • 

Hedxal Texl-boolc. With Indexes of Remed.iw and of Uihbhb and ibeir Kemfldic". Sixth 
EniTUiii, i«Ti»ed and improved. With one hundred and ninrly. three llluxlnliDnE. In two Inrf e 
•Dd band»()Die<y primed octavo vole., lealber, ofiboulUDO pagei. (6 00. 

Id sanuuelBg a aew editins of Dr. SaBflJua'i i Tha work will, we kiTe little doiitit, be hoashl 
tteneral TiMmpealiei and Uatciia Hedica, winive and i«d by tba laajaril)- of nnlical atBitsau^ iu 

jrhoae laeriu have been heretofore lo often ai 

iBBlly eitiilltd. II ouitaot be isppowd, however, . wilb 



will Biaily it 

fHoarek, ladieloBa aaalrilB, and elcarBBN y( n- i tad Um eapiaBBiRdeiei appendid to tbu Kiliinn i>f 
■KUkia, k falty «»auined by the annarHa addl- treat aaaiataaeB la the ael.'etlna (ad pieparallKn of 
'|kaab«kria^eia iba work.aad Uk earofal re- •vtubleromslM.— 0*»l«iM> Mid. Jaimi.WHC JU- 

ElOD to wliiob he b»flab)ecinl lbs wbiAe^JV. il. «i«*, J*>. ISK. 



ITEW RRMKDTES, WITH FORMULA FOR THEIR PREPARATION AND 

AUMEKISTKATION. Seveutb edilioa, wilb eilenaive AddilloaB. la one very largB a*Mavo 

v«lum«, leather, of TIO page*. %S 7S. 

Aimthereditianaf ll>e>'NewK«ii«dieB" hnviuf; been called fbr, Ihe autbor has endeBvored lo 
Bdd everything of ntomeal Ihat hae appeared Mnoe the publieation of Ike Ibki edition. 

Ttteutidei treated of in ike Totmer cdiliooa will tic found lo have undercoue eiwuiderable ai- 
puisiw is IbJB, in order that Ihe author nii^I be enabled lo iutrodiiev, ar lar as praoliaMe, Ihe 
RBaulU of the lubaequenl eiperience of othen, as well u of his own ohMrvaiinn and refleclioB ; 
u4 10 aiake the work olill mow denrring of tbe eiiended oireulaiinn with which the precedint 
BditJonti liBve been favoted by the prnle*tiioa. By an ealargement uf the pitge, the niinieiou ~ ' *~ 
... . teJwi'' - ■ ■ ........ . - . 



^n iBCorporated wilhoul 
M BMfiil of the antbnr'i worlu.— 
TUa fl&boraCe aad narlU volane iboald be 



■ (Kenee, for phy»ii-i< 



—Hint rtri KU. a- 



lurnBHBed by i 

■■ -■■'[ index ,,. 
lereadyi 



ling the hulk of the volume. — tnfum. 

■nd Kitementi, aecimpanicd by full refemoe la 
IB the ortfinat papen. — nw^nuntaH J(*nul 



ELLIS (BENJAMIN), M.D. 
I THE MEDICAL FORMULARY: being a Collection of Prescriptions, deriTed 

from Ihe wrilings and pracik* of many of Ibe mo«l emineoi pliysicisn* of America and Europe. 
Tageiberwilhlhe u'unl Diplstic Prsniralioni. and Aniidoie» for PoinonK. To whiob is adikM) 
•n Appendix, on the Endermic nae of Med Klines, and on ihe uae of Ei her Had Chlaraforni. T(ie 



14 



BLAKCHAKD ft LEA'8 MEDICAL 



ERICHSEN (JOHN), 
THE SCIENCE AND ART OF SURGEEYj being a Thsatibi «(i SoBOioi 

Injitiibs, DmisE9, AM> OpsRATioni. New and inpravfil Ampricin, IVmi lh*jw«<ni] «■!■ 
and caieriilly rEViHd Lnndon eililKin. lUuitrated wiih ovrt four hosdied en^nvingt on w 
ta one larae and bandii'tne nr-favn vofums, ot one ttiounnd clmiely priiii<4 paseft. '- 
niiH<l buids. S4 SO. (Jt.1 himni.) ' 

The v^rv ctio'ingnTvhed brar with which Thie worli bat> been Teee\vri on hoi h nidaorib 
tic ha» Biinulnlrd Ihe amhor to render il eien more wonhy or Ihe position tvhicb ii ha* n ^_ 
anained an a olamtard anlhorily. Every poriinn has been cirerally reriieil, nDmeraan uMiIti 
have been made, and the miinl watchrnl care- ha* brea eiereiKj to render H a cuniplele eipn 
oTllie mcvl advanced condilitn ofsriTsinl rcrence. Id ihli moRnEi Ihe woit has hpKn nnlar— 
■boul a hnndred pape*, while the ferlu of engratingn hnB been ini<reBMit by more ibiut • bi 
prnderinp rl one of Ihe mo»i ihoroufhly illimra'ed votiimed herore rhe pfflfe»»ion. The addtl 

bu been nddrd ui Ihia country; aome few note* aod occhlobbI illurlrMiooa faara, bowev 
jnlniduced lo elucidate Aisericao Piodet or prttotice. 
Il ii. JD ear hamblc jodfrmenl, drcidcdlT Ihe hftx i tirp cribe aprrUlaa, and no) d«eillii( blia 

thaiJHiHeh baokianDoiolleBc/priidueeitbrjtiV Finiir>ri[<i [i> wiimh' I'-r ' 
Lie iracbrn of (iirnrT la tbif oooniTy aod urvat I ^„< ,;,,,„;,,,, ,i„i,..,ri, .1...- 
Brilaln. Iitde«l.llb*BiaiHrarfrcal aaUiiri>)ini«D< |>;, 1,. „,„| ,>,.,(;'' i.r-.cii ,1. ., 
vorkisn nrmry rcpnbliibEd ■□ i]il> cDtuiicy within 
lbs Ia»l dlleen or Iwenly renm a< iril-booti Toi 
nsdfeiilMiidenu.ihi'U iw 011 ly osf ibai even (p- 
preiinmuri la Ihe rullilBicnl oribe peealiat wnnupr 

af xhvOToifitrlon.— WtaumJtHr, of Mm-opvI Surtrrf- 
tU Tatar 11 arcallT enhanced by a vary ooniom 
weU-irranned index. Were|ninT tbn a> one of Uir 
«a>|TBliial>>>i(aiilribiiii«n>ia Bodoru Mritery. To 
sna eniertnK Mi novfilate orpr«c>ico, we rfrard 11 
lheii»«t*irTkeabtr>ui<lewtilQ)<hsc>n>i.».li. He 
willludarulneuerilaiiulJa>iUa|kiiBLbniL(heT<>rT 



wiik mai|4T«n>rr w* aM it la asr . _. . 
NatluriOiJmtTial ^ BtKliciKfmJ SttrgiTf . 
Pto(. ErtcbHii'i work, fsi 11* *ih, Iim 
•urpaimJl bl> una bunitml and ni^t p 
futely ifiuflrared. Hrerjch in pbraialagi^a 
final, aail opCTiim rmprn'oum, iloctrl ■■•«,'«( 

hautarpariL— i«.a.Jla«.a<k4ffw<.J«KnaJ. 



FLINT (AUSTIN) M. D., 
Prareiior ol Ihe "niMirjr asd Pracliee n! Mtdiciae In Die fBivenrffy ef L,MtiTfIlc, Aa. 

PHYSICAL EXPLORATTON AND DIAGNOSIS OF DISEASES A 
ING THE REaPiRATORY 0HGAN3. In one large aod 
cloth, 036 pages. «3 DO, 






I, In point both orirranf ennt aad of 

.ilitT flf III trammeit nr Ibi nbkeia, 
!o lake IlM Gral lank in winki of Cbii 



upon dlKeall pbciounia.— £ii/aji MW. Jsunul. 



Wa iflcammaiid lb* traa lite IP every on 
Inrga eiEail anoa niea nnnwritmlly 
lidnnpca Bteiy p»«e. 1 1 dnei er«flt li 

reaiUbls booR. 




A PRACTICAL TREATISE ON THK DIAGNOSIS, PATHOLOGY, AKD 

TREATMENT OF DISEASES OF THE HEART. In one aeal odare mluM, td wlm» 

»)0 page*, extra clolb. t^lS. 

We do nnr kanw ihil I>r. rliat hai wi 
UilB|[«bieblaaaltritraUib«tlbiB,hli' 

iributHii m mdleal UtaraMre, iaoat npi _. . . . . ,. 

pa**» all tha oUan. Tba work II noM eDDpreb eb- apBB Iba bnirl ai a Irit-hwik, baKa*Ui|i 11 M 

■IvBiniuienpijBDdnioilinnadtothaTiewiiiwiiiB- ._-..-.--..-.-._ . . 

eiBtai. na daac^riptlo«arael«raBdnielbndlni]: 
Iht alitrmenta are oabataBliated hyAiela, and an 

"i'']bT«';b"y«?fi'«Sr'™%P^^^ "oVT?«-™7iib»''i.'.r,s*.?2"ii!;v 

la adaiirably einr, dlnel, and ttet Cma drrueii .... . . . r 

With Dr. WBlibF-a aseatltBI treallae befure n*. wi 
hove netetitatlan la aaylmlbal Dr. Flint'* hcHik ii 
Uabnlwoikonibetieart in UieEaillBklaiiaaia 
— £*j(*>JU(d.md Sar(. jraBfMl. 

WabaTaibnaaHfeBvond lo preaaal nnr rvaderi 
Wliharair*iBlyila> " ' ~ 



Terr 



or Ibid 



bi* obBscmima and aagKeaiion*, nad ID dinoC Ibi 
BiiaaiinB ot car breihren tu the abmuBUnC aUiiaa al 

Bid and iBiImciliDi. Nn medical library wit] bera 

band! of ereiT AmarieaB alBdcnt and pkylieiiui — 
JV ilBi. Had. Cttr. Jiiviiu. 

Thia laal work al Prof. Flist will add naeli in 
bla ptBViiniB well-earHd oolcbrKy, as a wtiiti H 



kind thalhaa jet appeared.— ^VaiilvUIiH 
AVllh more than nleoiure do 

Ihe iLoai nlaahle p 
Mid. Nnn. 

In regard lo tba mertta or the wi 
biaKalinn Ik prononnetag il rail, a 



But Ibeaa are verr IriTial ipnta. a 

nf Iba aalbor'i nbUily, iadaalry, aad 
neaa.— Didlia faarUrlji .fHrjial ^ mta.B 
B* baa labnroii on wfli Ih* aana laiaMry • 
Bad hMplaBennna|Uu^*Biiaibsranto«t 
iabtcaininirallyeakalilbhed. T« iliia and, Il 
wbcae title iagiTBB abn*e,BOnlTibnt(« la ».. „ 
degree. Oar apa:* will kh aifmii nf aa ollew 
BBalyala, and we wHI eFn^e I"-"- — * 



AMU SOIBNTIFIG PUBLICATIONS. 

FOWNCS (QEOnOE), PH. D., lie. 
A MANUAL OF ELEMENTARY CHEMISTRY ; Theoretical and Praotical. 

illinlnliOBS. Sdiled liv Kibket Bridoes. M. Tt. In one larse rayil 12Dia. volume, of oOO 
pHgea. In lealbur, SI dS ; eiir* clalh, >1 ^. iJuH luiuJ.) 

The dvalh oT Iha author hHvint placed Ihe edili>ri>] Mre of ihi« work hi (he praef iwd tiand« ol 

r«, Beace /onw aad'A. W. Hoffnun, everyihinij ho* hoBii lione m lis iwiiion which eipononce 

xild «uggv»l lo keep it on ■ level with Ihe rapiil adVHuce of obumio*! ncKnce. The udilitiona 

iqnialle lo Ibis pw])u«e have aeceBiJlBKid ui enlaqteiBeni of ihe ptge, nutwithnliDdiiig which Iba 

. ork bus \ieat \ncreafei by aboul flfly pugea. AI the Bams time uveiy oiira hu been u*td lo 

Btainilin ill diMinciive cbktneler a<* conitenJied iBaniMl Tur the aludBn I, di veiled nf all uflaeceHBrv 

'^lait nr mere theonliFal iipecnlatioB. The additioua hiive, of coune, beea nuioly in Iba depan- 

toenl of Orgwijc Cbemulry, wbiub bst made Hich rapid pnareia wilhia (he laM lew yeiira, but 

^1 equal allmlioii haa btwo beMowed on iho oihei braochea of the »ul^l— Chomical Phy.ica and 

laoi^anic Cbemiflry— to prewnt all liivef-Ifniiunf and dii^cuverio of imporlance, and to beep up 

ipula'ion of ibe volume as a ooniplele manual of Ihe whole acieope, aJminihly adapied for ihe 

-~ Bylheuae of a amallbui exceedingly clear lypatbe oiatler of a largf octavo ii comprssaed 

wiinm me convenient and piirtable timiia ul ■ inmloraie iiued duudivimo, and ai the very luw (irite 

JISTAb4. It ii odered as one of tbe cheapest voUiuJeh belbrc the profeaaioa. 






'Hi WDTfe liai baen uaivaiMltT 

BofUit tuniD'>aD<l ia vir]' (iMKrallTaiiiipleil, wr 

toth llMriTyaadHJailiHe.— (nUrlomllil Jamn. 
^vi Ahhw. 

■*■«. TheautharLiachievodlhediSeBlltniiV 
aoadeaaulin with naaurly tad. Hii bunk ia.cua- 
alagwithmillieing *iy, and briaf without being Ion 
••KinaEinI or genera] .— Vtrginia JUiit . oaJ Sarfiio J 



ri9KE PVKD PRIZE KMAVa— THK BP- 



X 






iltyar 



an'tTHF. Tk/i.IFKPJCb' 
TUBDEV - 



■adfKUafmnlernniiainiilrv. ThEaJzcgflha work. 
mJ .im more the oonrtenj^ yet pei.plego«atvle 

popular.— EdiiatHrci Jnutnmi af Sbdiial BHhu*. 

BDWiaoWriain.H.D.ofBdealon.N.C. Tu. 

..«hn,i=naoneHi8*" vulaoi.,Biu.clo[k.BHiu. 

V rbnalaffectUh 



d Pathol<igy. 



rlulb. »ee 



bSe 



FERQU«aON (WILL(AM), F. R. 3., 
Prnfraiiu of Balfcrr la Kini'a Ci>llnr«. Ii^dm, fte. 

A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third 

' aadenlarfed London edIKon. Iionetar^ aiiJ beiuililuDy prinuid octavo volume, ol aboul VUO 
[»ge», wilh3tt3 fcandsuitie illuMraltane, leaifaec. S3 DO. 

QRAHAM (THOMAS), F. R. 8. 
iCHB ELEMENTS OF INORGANIC CHEMISTRY, including the Applies- 

lions of the Science in Ihe Aria. New and much enlarged ediiinn, by Hkshi Watts und Robirt 
Bsmois, M, D. Complete in one large and hnndsonie octavo volume, ot over SOO very large 



c..-. 



Elemmiti,— SlIIIXHi 
m>K Pnf. Wtltc 
Theworkiiann 



I o«i», H. r. #v.. 



of. Omhsin'. 

I, i»se. 



Ho reader of Engtiih worka on Ihii tcica 

GH.IFFITH inOBEHT EJ, M. D., He. 
TL UNTVEBSAL FORMULARY, oonlaining the methods of Preparing and Ad- 

Biinislefing Offieimil and other Medicine'. The whole »dapled to Physicians aad Phnrraaceii. 
liHU. Seooid Edition, I boron chly reviaed. wilb niimernui* adiliiiiHii, by Hobekt P. Thomab, 
M. D., Prole'sor ol Matecin Medlca in the Pbiladelphia Collef^e of Pharmncv. In one larpc and 
llBndtonisoclHTOToluine,eilnidoth,of 630 pagea, double oolnmns. (3 DO; or in sheep, fS^A. 



«(ldii«waUt iB 

Mti»i> of iblh I 
Sorka Ihal haT 
£ would iId en 
pfiUily uieihin 
blui adaiiiwl I 



B cmajialHt from 91 



'Jail and nhamieBuiist.— VmiTii Laarti. 

aitd Sttlg. JturHml. 

1^iaedil<on baabDaa nramlK imimv^ byEbe re- 
viainn anil nnpie adaitiftni of Dr ThornHi anil t* 



u 



BLANOHARD « LEA'S MEDIUAL 



GROSS (SAMUEL □.), M. D., 

PiofcHaror Surferr In the J(ir<rv<iiM«lir(ICuircgB.nr PliIliideJpkMi,&a. 
Eolarged Edition^SOff Readj, lanoary, 1SB2. 
A SYSTEM OF SURGERY: Fathrtlogical. DiBgnoMio, TherapenttP, »a ( 

rive. IlluHtniPer) hy Twf.i.vb Hi!t.n«BiJ *i»ij T>»b:»tt-siviiii ENii»*Tras». Secniii! e 

■ inrfiilly revi-ed. In Iwo large and bumifully p' ' 

.. JJ....1 ... 1_ ■ 1 ^. 1 — .|„f_ -wnb n 



nboul iweniy-IWD bundhnl pa^a ; strungly bound in 



li niwd bands. Pritv $13. 1 



L this if ihe bei<l cTideii™ Ihst ihe 

w«nt whjeli existed of a eumpjule Americnn Svi 
ne«<>]>ary deiailn and in ill ils hninche». Thsi lii 
it •bown not only by Ibe rapid sale of the warlr, I 
b*t bn^n received by (he argtoi of the proles' ion 



■rge edilioa of x 

>r was HOI nislaken ii 

p of Surgenr, presenliu 

I «ncreeded in ihe ■IltmiH to >npply 

ilso by Ihe very ftvnrabfe nianiier w 

a ion iry anil in Europe, and by tfaef«clrij 



rapHy ihia 



rk of apprEciatioa not oflen beviovreiloa any ai 



It prciprBM ii 



preparrntr in Uollaud — a u 
lific work to exiended in siie. 

Tlie auihor bav nol been inMnaible to Ibe kindness thi» 
■lie woik for ■ new edition he liae spared na pain* lo rende 
has been received. Every portion has been subjected In cl 

ciencieB apparenl have been siifFptied, and [be recnlM of « . ^ „- ___ 

siHeeijr have Iwen everywhere mlrodoccd ; while the wriei of illil-tration* bai been dilarpdV 
the aridiiion of nearly inree hundred vood-cuts, rendering ft one of the moat IboroDglily ilhuUiT 
worku ever laid before ibe profesfion. To Bccommudale tbew very exloosive adAucM, Ih* i 
has been printed npon a smaller type, to Ihal nolwillulandin; (he Very luee inoreaae la the m 
and value of Ihe book, itasiw is more ronvenienl and le^« cumbromlhanlieliire. B^ 
been taken in the prinunB lo render the typiwraphical eieruii"" unoxcepi ion able, a 

y presenled e* a work in every wajr worlhy ofa p(ace in even ihe meat iimileil librvy of d 




elabnrate— too els boiatB— Willi rMpcel 1< 
diiHiatB, while tfcey kava aiBTelT flair- 

._ ,. . at. Gross h> 

ud III! prmliced the nu 
't Itfflnfcom thapreai 



thatbghaxnbnnd 



Ihclad 
ufnigii 

Ml'^B"l0»f!'or'i 
IliB Hpporlanily of Ifantfernng lo nii | 
admlsarar cfiirariars (rom Lutisk as 
_ _,«r.liva ■nthe^p.lhol.^^a.d I 

. d^^V- - 

pBliuDiige—Lmlaa Laaeil, Sept. 1, IKO. 



b»i fell by praelitioien; he has fisraialiM « 



ELEMENTS OF PATHOLOGICAL ANATOftlT. ThW edition, 

revised and greally improved. In one lar^ and very handsome ovtavo volume, wilk abual t1| 

bimdnd and Gfly beaiitiful illuslraiion*, of which a large number are from origisal ^wf 

Price in eilra cloih, M T.'i; leather, railed bands, fS 2S. {LaUii, FidJiihrd.) 

Tbe very rapid advanoes in the Science of Falbolc^isl Aaalumy during [be laal few yoankf 

lendered easenlial > Ihoroiish modificalkin of ihie work, with a view of making ft a correct sr 

noni of the preMDI stale of ihe snbjeel. The very careful manner in which Ihi* laak lsa» U_ 

execnted, and Ihe amoiral of alteration which it has undergone, have enabled Ihe aotkor to aay tl 

(• with the many changes and iinproveinenls now inLrodooed, Ibe w— ' "■ ■ — ■"-' -'— -" 

execution of the volume, rendering il <»ie of the bandsonM*! produclioiia of the Ame rw — p 

■aesesiCul nuBaariii wbish ha bsiaaeDoinllsheil his ral manner iawhioh Dr.Ornai 
propiHKd ab]»l. HU linnk is mnsl admlrablj eal- 






. 0^,1. 







e'lnpraheMlve difiM nf IW' 






AND SCIENTIFIC PUBLICATIONS. WF 

GROSS (SAMUEL D.), M. D., 
or of SaiTcTT in ihe USt>ifB Mcdiad CiliFfcor PhlUdelphli, Ae. 

A PRACTICAL TBBATI8E ON THE mSEA8ES, INJURIES, AND 
MALFORMATIONS OF THE LTtlNAHY BLAIJDKR. THE PROSTATE GLANU, AND 
THE CniETHRA. Second Eciition, reiiMxl Bi.d mmh Bnlarged, wall one hundred and eijthty- 
'-■if illustralionn. In one large nnd very haitdsofne uolavo volume, of orar nine hundred p 



In leather, raised In 



traelkBl iDfnmulioB 



:5 aS; I 



taeloih, »4 75. 






nrk la ih> R«thwb 
irlprincipliigniie 

>C IhCK dlHVMI.— 



GRAY (MENRYI, F. R. 9., 



b/'t 



iil,LoDdnn, fti). 

AMATOMY, DESCRIPTIVE AND aUROlGAL. The Drawings by H. V. 

" -- — 1. M D.plate Dsmon-'lrBlurDn Amnomyai Sl.GeorffB'aHmpilal; ihe Di-sceclkinsjoiollT 
AimiOK and Dr. CaRTRR. Seound Ameriean, rrum the reoail reviied aiiil imfiroTed 
eOiii.m. In one mugiiini-enl ImperiRl oolavo volume, of over 800 pugen, wilb 3SSUrm 
tiid elahornle eiiRrovingi on wood. Price iu eilra clolh, (6 S3; leRlhei, raised bauila, »7 00. 
(Ifota Riady, t8U2.) 
, Tb« rfveiy «xhBiti(tion or> large edillrai ortfaiyrorh In auincieni rvUmee Ihal lis plan and ese> 
.jniiiun havebeoQ Tound lo presvnl sDperior pnu.'iiol nlvRDianiiiin Acilluiing ihe-Bludy ofADWA- 
yy. In pnswnling it lo the profcAiiiHi > Hi^ond lime, tbe BUinor baa aTailed himneirol the op|ior> 
Nuily 1(1 supply any d«Aeiencie» which nperieaoe in ila aae had ahnwn U 



oinpMci 



fBCteitpe l» liable. Thene improvemenis hare fewil led in pome incm^pln tbesiieofihe ToUtme, 
rhile imnty-i'ii new woiiil-irmi have been Rdded lo the beBuliliil seriei of illii!>tralir)n« which 
:tinc1iTeBre*liirei>riha work. Tlie American ediljan hH* been pBNied through Iheprena 

. iiipervirion of* oompeleni profB*Mon»l man, who ho* laken every oar* lo rondef il In 

|l m>|)ect!> BCc\irBle. and It la now prwented, wilhoul soy inQrea» ol price, ■■ fiiwit lo malnlua 
od eilBtid the popuUrily which it has everywhere acquired. 
I With liiilatrflubte. Ilia bair pfBotitiofltr wbii» , In exiil la thli nnnntry. Mr. Omjr writ** thrnaih- 
aw>wl«lgear>nBtciBiym(ThaTetice"iaBnliacuriidby I imi with tiutli branchn nflila nli]pcl In rirw, Bli 



1 



of practice, may B ...._... 

' tore, ami be ready fur aay emoraiiairr' "•"•« >^ it* rrl 
itlansf ladividaal*, and tini in ibeBu- diiiuie 






Tollowid bf a 



la oprntllra aBrffsoB. Aflar di 



liBWorkwill BilliBBialy lend to IbenurpoKao _, 

,.^ j..'_. II, -■itaiBtni iiT lbs rnolwrea to which Ika h™™ wi 

e eatrwnlllaa are mail liable, tecrlher with Um 
iuiBatuiddir«tliiBiif Uia dliplaeaaeal U which 
e tn^aietu are inbjccted by nmaeular apiiiia. 
i» iHtino OB arterla* it nunrJiBbly TbII and ae- 



















a naeta iai proved a 


;rt-„ 






a"?i"J"f"»l«B 


S'-A 



,JrDrli doet B»i 

i. Thitedltina 
«D*laii» HVer 

!«^^Tjw_vjd 

Tbeirork heTnie bb 1b nne <Btlll»d In the ht(he<l 
inlae, nad wa BCBotdlBBly welenine It ■• . mlu- 
_u. .jj™^»b ff, BteiiemS Ittti^tan. iBltriacillile 



rawlof Wllara, II 



IhD ] 



of 



MMIIB. , Moat or Iheae are orliiBBl, oT Biscb 
■ner ihaa nrdinaTy ■lia,BBil adaifnbly uHDinl. 

<(ipM la BnldeB>a Oaieolngy. [t wnnld bt, oifi. 
■It. ta ovar-aallnale ika advaniBBei 
■Ode or BiClnrlal lllB.iiation. ^oi 



r BiClnrlal lllB.iiation. ^oaei, lirnmrDla, 



XCDBbllnRtheatDdcBliociinipiehi 
MI would^irtberwiaa ofteaba Igi 

aeqBlrH) only by pruloBcsd ai 
^Inn, IB eon«liiiinn, we Kurd 

I one itf ike Boaf valcible conlriba. 

I edacatlmal Ulantaie — N. T. ItmUklt SivWt*. 



irktnme ■■>■ 

the nnlieal 
bflre^rded 



new, wc rof «rd 



■ hettet Bdaplei 



Llomy j'clpuitli'hfd Id IhiBfOaittTy. 

believe, (oiuprnede ill nihen, bo 

tl ilaarctiana, aad ■ Uaiidacd n( m 
BtBdeai of ceaaral 

>wl>lt Inly Minilrabli 



rMr. QnyaK 



Ronie, affording a enmplBta view or thi 
Ilia BaraaB body, wiih eepeetil referencB to nraeiieu 
■ura:ery. ThaatlievnIanieeoDBlitBleiaperfecibwdl 
or rrfrrcnecror ibepnetltioBer, demaadlDia place 
m svea tba BHtaElinlled libnry er the phyalabu m 
iurf(im,«nda wmRoTaeoeBBity roriheitp<r~* *- 
fix inhlaiahid wMtkehaalMnwdhT thediei 
HDirefrani tbe bwk of Batare._T*a i)> " ' 
urfp Joimuf t/Mid. Scuwji, Nov. Itv 






lo our lBi1j(m*Bt. th 
(■■l»ee to thE Btndei 



■araeMly deairOBa 



IU adopted 



will heaABBdoubted lodaBBd. The peeuFrar rilua 
•>r Mr. Ony'i aioda srillBilnUoii iaaawhere nnre 
anikfdly avideai Iban In the ehapter on oslcolarri 
inil eipHidlT ia thnaa pnrtiooa whisk treat at the 
brinri o( the iigul (Bd oT Ihtir deiralupnenl. The 
■ludyortheiaiiaruiittaaaiaBdeoBeori 
Dnie, if Botorpniilivepleaaare| and tbi 
_i-.L_ _^..j__.^ ji^^ lempnrai aDoephDno 






B1.ANCHAKU K LEA'S MEDICAL 



llnSON'B [NSTITUTKS AND PRACTICE OF 

BRY. Ki(hlh Hlilt»D, Inipiwed Ibd ul 

Wiihthlilr-rnarptiii<^i. Ir lwnh*rid>.iire 

LitsiIb«D<f'. to CO 

■8 BSKDICAU CHEMISTRY, fnl the 
IVnu.voJ., elotk, pp. MC, witli wixul-auci. ei. 
l.t'OE'B ATLAd OF PATHOLOGICAL KIS. 
TOLOOV. TruilBled, HiUi Kauit lai Audi- 



tiimi by Journ t.iTDi,M. D. In bma^. ._ 
lupper pi»lB lipirel, plaiD Mil •iiTuteil, '•« M 
HUGHBB- INTRODUCTION TO TBE PRj 
TICE OK AL'HCULTAriDN ANll OTH 
M0DKSOFPHVSICALDIAGNO8IS IN 8 



HAMILTON (FRANK H.l, M. O., 

Profti...t uf Surgery Id th* Lung liliad Collpge Ucpiul. 

A PRACTICAL TRKATISE ON FRACTURES AND DISLOOATIOll 

pag'^^r.«IillinMrly'300U]'uslrWKtnB. \j.nC Siuulf i 

The earlT demnid Tor ■ oKV edilion o( Ihi* wnrli Fhnw 
IhrcrHiliHrnreorihe praresFion b» a ilaiidan) auThurily for 
■m and ilifficull tuhjeoi. In ngtm iuu»iiig il Ihroiigh the prei 

nily M ravise il carefiilly, and inlroduce whatever im 

rifierienpe (Dd ob»rvBlion. Aa addilional cbapler i 
il Etill more lully lo the eiigenoiefeof Ihe liine. 

Aiamg the many good worli«r«al«srptr7nf whom When wetay, 

Isgi HsDilloni and Ihe volan 

Il wlilii piniar WoBBdHl pi. . .. 

iflit JhhiE m the aabjeel in Uia Etgllib li 



practical inratrywkleh wa wwlit a-uaai teedtn- 
nruA lo ourlirntlicc aoFSrom, eapMiaJly Ihoae of 
" [he arrTieei," oifhuaawtiaHpnaticeriealn ilia- 

awii noaided nanareu. The praeiiHonn will find 

eHilrroBOd and campiehnidedi and RiBnb pleaaani 
■ Eadfni [or him lo mnie over In (hearicrcunridTa- 
Unnuniiacaaci.— fdiatarcmtrf.Jaanircb.lECl, 
Tbla li ■ TajDihle coBlfibutioo lo Ihs BHr>er)> uf 
moat ioiponail alHtiuai.and la Ibi nwre welf ojne, 
iMinaskaaallliBpmwilt linewa do not nxaaeaa 
m aiBglg eoaipleU inaljia on Praemrea and Dl«lo- 
CBIlonilii Iha Bngllah laafnaia. II baa rcmaUiea Tot 
oat A&siieaq brctther UprDouee a emnplete traatlaa 
■pan Uig aabfesi, aid bilaR logaiher IflaounvoiieDi 

been nuda frun time lu lima In tbe treairaut ortheae 
affeelioDi. Ooe gmt asd nlaable realnie ia Ihs 
woik brrure aa ia Ibe faot that II enmptlaea all (he 
impmrementa istrodiiced ielD the practice of both 
liB|llaband Anerleaaaiitiien.BBd Iboufh ritCron 
(unltliDanealioBof oarcnsliaenlal Brlfbbnra. the 

pnTmlenI In xnne qDatlera— that nolhlac ia gnod 
tulei* Imported tiom Prasee or Oernan]'. The 
Utlei bair or Iha work la devoted to the euaaidera- 
liiia uT the vaiioiu dialooaiioaa and iheir appropii- 
>te trulmenf , apd lli meiil la Fully equi [u iliat of 
(he pTBcedlac potttoB — Tkl Losijeit !,■■(■ f.Mav S, 

isaa. 

_^]t i_a eniphnlicallT iJu boak upon the aiib]rela of 
e pecl«l of time. 






ridicil and SartMj J«*n>ol, Marek 1, IS 
The work la eoneiae.Jaitieluaa, uid aiwat 
lapled lu the wanla of the aladeut, praeutisi 
Id inveallgalot.hoDlirableloIheBalhoiaM"- 

We renrd thl* work aa aa hnnnr an 

iihof,botio iheprofeealoBof oareowrtij. 



Bewbodne. not. will 
Dr. HuBillon la fortunate tn haTlai 






,._ — mudBlnonvnpbfaa 

reapeeta, and » work oTeUuiiEal ulkcirttr. 

■IncerelreonaraiBlalethe piaTetalna Of UwUT' 

IVt have relit_ 

of it aa an original work, bnih InalllentiW 
ealifie pulBt or viaw, aad toHteaai III 

be widily ki 



BUAe puint «] 
ulda in a nK 



ile.aDdrurthei, 

Lb every on* naj prol 



M. D. 



HOBLYN (RICHARD D.), I 

A DICTIONAET OF TUE TERMS USED IN MEDICINB AND T^ 

COLLATERAL SCIENCES. A new American edilioB. Kevi:sed, with aumermiiAj 

by Isaac Hirs, M. D.,ediiorot Ibc" Americuii Journel oflhe Metlioal ScHiiiue*." Ina 

royal 12mo, vnlume, lealher, bf over 000 doubte ci>lumned pages. SI SO. 

To both practltinner (od atndenl, we leeomtnend Diei enibracing every dcMTtmeBt of nsdlwlt* 

tbia dictionary aabr log eoDveDienl in lize, arcnrate . dnwB la the very kleit date.— ITiilini Ltrntf 

iB deBoilioB, and auffiolenlly full and cwnpleH for Hoblyn'.DicllcBiBry haa lone been afc.olU 

ordlaory oonaBll»l.™.-CA.rl..<«. Mid. J.-n.. „,. i,'„ „,, beat bubk et defio.ti.n.a we ba* 



lietiuDBty belter arraiiKed and ought alwu 



Smhtrn Hi*, sod Air<. J»'»J. 



HOLLAND'S MEDICAL NOTES AND RE- 1 TOI.OGT. Elih lb edition. Eileeai 
FLKCTIONS. Ftoralheihiid Londi.B edidon. and niMlilleil. In two Utae vcUvo villi not, 
' - ' -- ■■ — ' '■■' -' morolhBB loMpBgee, arllkOTet 



JOHWBH-B 8PEC1AL AMATOKV ASP B^a■^ 



lire IhBB low pBgee, arlu 
WW. ■* — 



AND SCIENTIFIC PUBLICATIONS. 

f mftMor of Midwifcir »c 

OS DISEASES PECULIAR TO WOMEN, indudinft DispIaMmeota of (he 

I'rerun. Wilh ofigmal illmlrr-iioii-. In one tKauiifully pmteil octavo volume, of neorlv 500 
TWgVP, extrm elolb. »32S. (JVbw RsWy.) 



.vroHtfr w «4A nivumi iianvtvcrj and w« aav, n**» 
tM BkrijfkD whn 4mi n-U pkcc It In his libmr;, 
WmI wfin dmii nut MllirBlly cm Iti iwin, will Iok 
■ nit dF-il or knewirdie lUl wndkl bs nntt aierul 



rifSt-Jo Uttffasf JtwiHt, Ptb. u 



.ptlllll'lfj' BO 



or aMiia of iHa dinM 
unuK&ll toOHBtwiUaramt 

'^Bflka^rU'BlaT luMiri uf which the 



aulrtiw by vkli^ thrv ara invinablr altrBdcd) 
Jkeir nhMlnacT, ilie rfilficolnr wiih which they lie 

M<?(ir— Ubbc, UklB In coBnictlus wtlh Uia eaiiis 
Jrmpctcnsi' oC the auihiif to irnilei ■ enrr«i ae- 



na Ut * *lr«a(er, if, pereB>aee, bd equal elaim^ 
Affi. Autm.. ».d StbacM, Jan. 1601. 

lBi1efd,BlthnathBai<B[tDriheTalBnie»nDleml- 
Dentil' deierviiignrperaMl and iiiM*. we think thai 
the Blue elmnCFta aevoled lo Ihii nbjeet, ara ttat- 
eiallvBo, Bnd wekBowornomnrsraluuMt ni>n<'- 
gr>ph ap'S the ayiBiHnm., prngBu.t., and ■n^n"i^ 



Amitic*H Jtumal, Feb. lEfll. 
or the rmut eieel leneei of thenrnrk we will a"i 



re ill original, nre drowu in 



li of iu< 

nrm Brain ofone-bslf 



idf Itwith rate. The 
Im. Mtd. Monlklt titd 



CBiindThrmpeolici.lGii)i'.IInipltil,4a, 

PATHOLOGTCAL Af^D PRACTtCAL OBSERVATIONS ON DISEASES 

OF THE ALIMENTARY CANAL. (ESOPHAGUS, STOMACH, C^CUM. AND 1NTE3- 



JONES (T. WHARTONl, F. R. S., 

PrnfannrnrciphUiBlniicMeiliuiosBad Surgery in UDiveriiiyCnlleee, Lnndcm, Aa. 

IHE PRINCIPLES AND PRACTICE OF OPHTHALMIC MBI>IOINE 
AND SITRGEBV. 

. Uof pital , dec. In at 

[JONES (C. HANDFIELDI, F.R.5., ft EDWARD H. SIEVEKINQ, M.D., 

A. MANUAL OF PATUOLOGIOAL ANATOMY. Firat American EJi^on, 
- SeriKd. Wilh ihivE hunilml and ninely-xeven handsiiini^ woodengravingi. la one lirge nnd 
beanlJItil oeuvo Toliime of nearly 700 pagea, leather. S3 7S. 



\ 



j,iniiiiBlnin»,ln aeondeaHd i obtlKCd (oileBB fromagreBtDBinberof nn>Bo«ra|iha, 

Itom.fteoiBjiIeteoalllDe iir what la kunwa in lbs | aad the Held WBaioeileniive thai bnirewaurtiVBIe'd 
ioiMlBof hlhological ABfltomy.It ii prihupi ttii I It with asy dettiee uf lucceu. Ai • iIid pie work 
•«al walk in (ke Kkliah lui|ua», lis grent merit I of rereceuce, therefare. It la or freat raloe to the 
«M(iaia In lu aiimiileteneu andlirevjty, and In ihla itmleiii of pnihalcwical aDsdimy, and abould be in 

.|(l«ie. HolelarDre ihe atiidenl or pBthulugy waa I 

tCIRKES (WtLLIAM SEN HOUSE), M. D.,- 
A MANUAL OP PHYSIOLOGY. A new AmericM, from the third and 

improved London edition. Wiib two hundred tl[iii'lraiianF. In one lirge utd haadBome roykl 
13iiiO. volume, leather, pp. 566. *i 00. (La>a/y Puhliihrd.) 

ThiBiaa aew and very mach improved edition of i ud ita wrerolly tiled aalhorltlea. It ia llif mntl 
Dr. Kirke*' WBlI-kaown HBodbDok of Pliyaiolog^. | ei>Dvenleolnrtul-b<«ki. TheaegeBtlenen, Meaari. 

tkonfnra.Bltnilrabiy adapted fir coBautulinn br the we want \o kaow, without Ihlnkini ll Decriiary 
baarprtetiliOBer.— C**l»9HrHrlv7B<iniaI, to lell oa all they know.— Butn Aid and Surf. 

pMBMB-preaentingjudiuFbanoBlIlnaoriheaei- pnr Ihe atudcnl b»lRnlni tbia atudy. ai 

«aeeBBlbe BtBdantreiDirei dunii« hiBatlendaiin .i.: l. ...... .'L: .'.',._. 

■pnR ■ soarM er Iscmrea, ei rnr re 
yrCpariOf For auniBilIno — Ait. Mi 



l/t>rMl. 



BLANCHAKD * LBA'S HEUIUAL 



IK PKtXa> I 

:dicai. (IB- I 

_ r... a. Vm 1 



KNAPP'STECHNOLMOVioi.CneirnlryippHHilLAycOCK'B LECTURED ON THR t 

l« Ue AtU awl t» MaDufiKituriH. RiliUd bv Dr. FLE9 AXD METHUtIS OF MKDIC. 
RnNiLD*, Dr. R imi(ii>i(ii>, una Prof. w. B-| SliRVATION AND RE!<>EARC11. T.n 

JoBKBUx, Intwi-MDdMifiii 8vo.vali.,wlU«bo<it I u( Advaqccd Siudenit und Juaiur Pned 

KKJ wiwd cnersTliifi. M 0(1. | In oso myB] Itino. volume, «xl» ci«h. hiall. 

LAULEMAND AND WILSON, 
A PRACTIOAL TREATISE ON THE CAUSES, SYMPTOMS, ACT 
TREATMENT OF SPEHMATORR»(EA. liy M. L"ALi.tH«r.D, Trnn-lBled luid ediifd In 

Heiey J McDoiiCALL. Thifil AmeriMnediiion. To wh.rJi f» Htided ON DiSEABES 

UP THE VESICUL^ SKMINALES; Ann THim associated otoinf. Wixti eptxitl rcfcc 
cni^toIheMorbKlSecR-liuKaiil'IbBPriiPlslii.' and Urelhral Mui^out Membrane. By Muu 
WiL80N,M.U. liiciuanaatuclavoHu1uiiie,ur>>liou140Upp.,HitrBoloU. S^ 00. (Jwt /uM.I 

LA ROCHE in.), m:o., &c. 
YELLOW FEVER, cooBidered in ite Historical, Fatbologicol^ GtioIogioaJ, ud 

Tbeiapeuiical RelBliiMii. Including * Ski^irta of IheDiKBiw aa il hu owurred in Phiiadelpha 
(fom llMiio leSJ, wilh an eiBminalioa ot'lbu cMnnrol.ons between il Bn.l Ihe fover- Icnown awi«r 
Ihe fiimo name in oiher parla of temperale u well a» ia lfo|iidal regioDS. In two lBr(e Ml 
lofnenrly ISOO page^, eiiraololh. $7 00. 

and unniaiUKuhl* dlMWKe of ■ 



A moDUmrnl of ialtlliceal andWoll appliFd rr- 
■Hrch, ilRioil wilbDDL e»niple. ll >•, Indeed, in 
Itaeir. a larga library, ami la (taillDed to faDilltatc 

ill bjISt" whkh i'tr«l.™o idl r«B«*llM."' 

WabaveaolUiiiealpriiKal, eBfUgad aawa aie, 
by d*f and by nlfht, in Ihe work or conihilln( thii 

thu aire Ui'la suwiry Botleeor whgl we eunaidec 
rlaw of tbe atarlting (act, Uat thii, tlis muil malig- 






Enuaeii tbat Ilia Inatc/wii 
eeaa now Ihtn [hiny or f<"i i 
iacaataiichiefdaaetiTlrnor" 
ledniB regard totbaaiaeaB^ 
bability thatanajorlly of a.i 



ally le 






OBlb.— iUim^iii Utd. Rtr-ia. 



PNEUI^IONTA ; ita Supposed Coanoction, Pathological and Etiolo^oal, iriti A» 

liimiial PevKrs. laoliidlngan luiiuiry inio Ihe Eii^leace end Murbid Agency of Malaria.. In oa 
taand^ume oulavo voluuic, eitra dulb, ofSOO pagee, S3 DO. 

LAWRENCE <W.I, F. R. «., &c. 
A TREATISE ON DISEASES OF THE EYE. A new edidon, edited, 

wilb numemu» addiliona, and 343 ill uslral ions, by Isaac Hays. M. U., Surgeon lo Will'- Hi^- 
IbI, fee. In one very large and lLaDda4ime oclBVO vtiluine, ol SOO pogo, slrongly boand la leubei 
Wilb raiwd bands. %5 00. 



LUDLOW (J, 
A MANUAL OF EXAMINATIONS 

Prapl,rE,.rMcdici»e,IJb^leIri«,MBlefiaMi?aii-t 
whioh is added a Mttdical Formulary. Ttaird e 
and eulerged. Wilb 370 illualratiuaa. In one 
large pagHa tS 50. 

da(in|lhe linaraai>elitiB thslceture rnon, nr in re- ' 
(reali, ai ■ glance, bliinemury of Uie varioua luiiicai . 



, M. D. 

1 Anatomy, Physiol n^, Sargerj, 

miKtry, Phatnaacy. and Therappiiti». T« 

'■-—oughly revised nnil greuily eiixiulad 

ruyal ISmo. volume, leniberi ol SIS 



Kunlie's AilaS ot 



LEHMANN (C. Q.> 
PHYSIOLOGICAL CHEMISTRY. Translated from the Becond edition bj 

GeorceE. Day, M.D., F. R.H., aco, ediled by R. E. Rookks, M. I)., Pror^awr of Cheniairy 
'e Medical Denarlmenl of the (Jniveraity of Penntylvanla, with JIIuMrBtioiM *eteeied ftm 

i»of PhyEiologiesI UbemiMry, and an Appendix of plslea. Compleie in ivu larg* 
lea, oxtrn clot n, (Containing laOOpageH, with nearly Iwo biuulred illnt- 
[ralion:-. %« 00. 

BOtlcoinprelieniivebaokaf refer«iee*DiliDforina- Phyaiul<«l»l CbeiulBlry_^M. Jiana^ JI«A4^| 

BrTOSftAME ACTBOR. [LoUlf Published.) ^| 

MANUAL OP CHEMICAL PHYSIOLOGY. Translated from the 0«raw, 

wilb Note* and Attdiiions, by J. CttEsron Morhib, M. D,, wilh en InlmdiiFlury Eeaar oo Toal 
Force, by Frolesoor Samuei. Jackhon, M. D., of Ihe Univarsily ol Pen^^ylvanis. Wllh illw 
traliuui^ on wood. In one very handsome oolavo volume, exlra ctoth, of 336 pages, ta '£i. 

Prow. Frof. Joetton'i Inlrvdutlary Bita^. 

In adopting llie handbook of Dr.Lehmann a> a manual of Urganie Chemistry for Ihe U'e nl Ub 

■tadenl* of Ihe Univcrtity, aud in rucomuieuiling his original worli of FumouiQicAt. CnKumt 

for Ibeir more maiure aludies, the high value of hit reBearpbes, and Ihe gfeal weigni of bin autho- 

niy in Uai imporiaai dBpanmeiU of caedieal MiaaM in Ailljr raoogniied. 



AND HCISNTIPIC P [JBLICATIONS. 



31 



u Fever. 

De, of 3ta 



LYONS (HOBERT D.l, K. C. C, 
Lits pRlbnloKiit ia-i!hief Ig itic Bi^tiili Arm; in Ike Crlmu, Ae. 

A TREATISE ON FEVKR; or. selections from a coiirne of Lectures 

Beine pari of ■ iwur>e ol Theory and Pniclice of Meilicine. lu one neal ocIbto vo) 

pmgii>,(iilnololh; S3 00. (iVav KioJv.) 

Wn have great plHiurit In renifninrDilIng Di^l Hob. WttRnaitder Ihe work ■ naiC valublo uddi 

fHHuB. It luswDrk vbiab nnniM rkll lofnliiuiia nn little I nil upnaa ovei tBemiailaf tliiipn>muaB.- 
thennlhor'a pr'Vh>Di WFll-«iDid »<|>eii>iio<i. ■■ u MiA mmd Sm;. Ripttut.Mty t, imi. 
U^yii;*'"Y">S "hi'mi'" ''''""""-'-^"'"'' Thi. I. u edaiiiKblo work upaa the noil (onmrll 
T-kin ■• ■ whole m nn nruniinrwl il in Iks I nxniiind ire linble— Miif. Jaum. oIn. CnrtfiM 
biKh'ii Icrnii » wsll wnnbv ih> f^urFrul peiunil Maf, IWt. 

MEtQSICHARLES D.), 
Lilelr PiorcHoio 

OBSTETRICS : THE SCIENCE AND THE ART. Fourth edidon, rcriBed 

■nd improvBd. Wilbsae huntiredand tweifiy-nine iliiialrationi. laonahesxilirullv nn'nled iwliVO 
Tolums, lealhsr, ol wven hundred and Ihiny larife pages. t4 00. (JVov Riady, Kcli. 1HG3.I 
In his FreCaee the aulhor remark* : " In this edition 1 tiave endesmred to ampnil the work by 
ohanfte* in tn (ofin, by tiareful eiirreoHon« of many ciprenBiont, and by a fbw omisBioni' and iMinio 
■ddilioi)" a» (□ thp tell." Tbe sliidpnl and prBciiiioneT may Ihererure lely on flidiug ihe riilArcl 
Ibnruughly brougitt up to llie present lime, and that the new edition i> Worltay a colitinuaaoD oflhe 
TCiy great favor wilb which the wort has been received by tbe prufeiaion. 



I 



terlal, all avlBm a llnlydHlra thi 
to be reurdad ai jnproved in ~ 



ifbutif ineipnngiag* 



■albor 



»."\.toiiihl 






Mid. and Sf 
■ T THI M.ME AtTTHOft. {Jiul Ilimnl.) 

WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Leo- 

inrei id hii Claa*. Fourlh atid Itnproved editioti. In one large and beauIiAilly printed uctar* 
TolumB, iMlher, o< over 700 pages. S3 60. 



theiiidinpraiieorUiiawork. Ii aHmnda with ilteBtion of the r»[J<r^itaiiMi>e'i 
laiiCnl paiEsiu, and fur enDCiarncM, Tor nrig^n- ,. „. 
T-indfornflllialiiBDniaundabliiiBawotk oa | ■•'^"<>«ii» 



o the 



■lltr. and (or mil Ibal ii eoniaundablo in a work oa | " =™«in»'i »mi amoant of prarlieal knowledge, 
IhediieiiFa orrmuilBi, lliannleuelled.andpra- V "'" *!>" h.i arcuiaWly obierverj and rrtainod 
1iihlyni>(nuall«diiilbeEbrllihlancuaie. Ob the •'"' "pefeaee o{ mway yeaii.-Il-Miii Qun.rlii 
whole, we know of ao won nn lliedI«™iBa of wn- I .'"■™n'. 






le before Di.—Ok<e 



die' FuTlofimpnrtanl 



"''."I'i'l..«m.» ini™iln and rare e..« and 

uTDr Meigi, with ■ hiRh npin'ion of hii talenli and 
nrigioallly— ni fir^lii* awl Ffnign ItedUe-Vki- 

Even chapter [a replete with praelieil litatme- 
tioB.uid beara tbe injiTBu of being iko eompuntioa 



tieanednen iafi-etini tbeerir'l oT Dr.'Mc Igi. whleb* 

rlea the reader IhmugH'fron b«laBlng tn end\ Be- 
lidea, the bnok teeina with anlid Initruei^io, and 



with which tb< 



h'.obSJT 



Prof. Mein, are ianlated and n 
CkatUilQit am. Jttmal. 



ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED 

FEVER. la a Series of Lellerx ailitreaied lo the StuiiunU of lua Clua. In oiui handuioe 

OElsvo volume, eilra elotli, ol 365 pagei. ti SO. 

The tnatroetlve and inUrealiBg author of thla i 1»table )wnk. » « • Thia treallae nnoB child- 
Work, wbnaeprevioDa labon have Dlaeed hit eouB bed fevera will have an cxtcaaiva hI», heiBI dea- 
Irjnen oader deep nnd abiding oblifatluci, again tinrd, aa il deaervea.lo find ■ place in tha ttbrary 
Vhallnigfa. Iheir adn I ration In Il>a freihanil vigor urevarTprarlilimer whuaeornatnlai In the rear .— 



A TRE.ATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK 

up TH£ UTEUUS. Wub iiuni«roui olaie*, drawn and colored from nuure in Ltae tii^luiU 
wottwn Toluma, aim doth. t4 50, 




BLANCHARD * LEA'S MEDIC 



MACLI8E (JOSEPH: 
SURGICAL ANATOMY. Forming one 

Whh Aiity-elghl Ur^e and iplcndid Plilen, drawn ii 
tainrng one hunilreil and nineiy Figures, many of II 
and vxptaiiHlary leller-prvf^. Slrongly and handHii 
chea|>r*1 and busi eiecuied Surgical worbii Bi yel it 
*,* ThoJieofthla work prervnlaltslraiK'niistuin 

Who dciireln bave copiei Torwarded by mail, can recei 

wrappers. Pricso $a OO. 
One iif cka pMtcal artlitie trfonpba i 

Ifl Sargical Anatnmy. — Uriiiiik Jnurica 

JniHl. / 
No praeiiilnnct whoH tiimd*wI11 adr 



rail 10 



•l^lilr 






(TCT pnbllthed. — BtyFol* Midieal jtui 
ry can thai «> ileganllr pr: 



and and beHtirally 






-X.Y.UtdicalGaiiiu. 




A WDik whicb haa n<i eamllal in yniai a< vtH- 
racy iDd chriipDcii la (beKBglialt Iwiyiwae^ — X. ?. 

Wc an iilrrnislT ^tiEed lo ■nnanBH U tt* 

work, wliwb, ai a wh-ilo, cerUinly alaiult aai- 
rnllnl, bnib far aeeanFr •>' drawUR. Ipaaair it 
ciiliiiing, HBd all the rcaniaite explvnaliom atOi 
><ib)rrl ID h>n'I.-T*< fff OrlaBu MmMmJ a^ 




eaualuniical 1uiiwl«l«e, ■ work 
kMpi IhrdMniljuf lh«iliti«!tiBK-ru«'«i perielaaUj 



MILLER (HENRY), M. D., 

Piofeaior of ObiWirioi and Dl»r»>r« of Women and CbilUMa In Ibe Uaiverattr "f Lowlwrnle. 

PRINCIPLES ANU PRACTICE OF OBSTETRICS, &c.; inoluamg ilie TreU- 

mcDl of Chronic Iiil1ammntii>n of lb« Cervii add Bujy of Iba Ulscua cAnsidereil u k fnijiKM 
eaufe of Aborlion. With about one hrnidml iliiiptralion" on wood. " 
lovoinilDnie, ofoTeieOOpngea, (LaUfg ^UUAeii.) 13 79. 



Wocimrn 



on the ptiDciplea and prastiGi 



ta mcriU jnallr «DttIl 

ta rot bim a kigh insl i* Olicnued and «lni-h1ated witl 






medical pi 



tiai ambadylag therHalUof theatadin, rafleelioni, 
and expaifrna of Pror.Millgt. P«w man, ITany, 
1b aiieDaBlty,«iamaraoDBp>i«iiiliBabetnwriM 
OBthladapartnuiBtnfmediaiBa. Eaguedrortkltb. 
IvB yeari in u ulaoded praaticc or ubaiatilo, fat 
many yearaa t«aehet of inli bmneb of Inatrastion 

atadant aa wall aaa MnfBl abMrvar, aa arlyiaaTaiHl 
Indapendeat Ihinker, wnldnd To an faobbiaa. aver 
taady lo noaaiilBr withon 
* to adofit inaunilinu If thi 

iraallia from bli pcd eoD 
Talaa.— Bi>/U« Ultf A 



rill find nunyrcadera and warm admircrt wbarcrtt 
ibatdrici ia laugbi and atudleil as ■ mtiimcc aad aa 
irl — TktCiiuitmali Lmnaiatut Ob—rrtt. 

... . - . allka on Ihaaolbnrand tbo IsalitnUm (p WBKb be 

roJadiMBBWTMwa.aDd j, ,ti,i|i«l. The Hudenl wiU End In (bii wurl ■ 

aally^lmprDnniaiLUj moiIuaefalfUide to hli atndleaj the e..BBitT pra»- 

'"" tolly in bli roadinj, oaa nbuin rrnn ifi 

■jr rCiuma of tha moden lllenluie i4 Ike 

enlly eonnDlteil by Ue profeuian.— ra. 

MACKENZIE (W,). M.D., 

flncgennOCDllit inaeotUndtnordinaty loHerMaJeity, ft.c.*e. 

A PRACTICAL TREATISE ON J>ISEASES AND INJURIES OF THE 

EYE. To which ia prelixed an Analomieal Inlroduclion explnnalory ol ■ HoruinnuJ SpcHuB M 
Ihe Human Eyeball, bf THOHAa WBAKTonJONie, F. R. S. From Ihe Fourth K«vi»«l and Eih^ 
Isned London Edilion. Wilh Nolea and Addiliont by Addinill Hiwhon, M. D., Sur^nw Or 
WiilnHovpiUl, JEC. jcc. lnonererylarEeuidbBDd!OiDeoclBvovolume,leBther,raiaedbiuida,witt ■ 
plales and Dumeroua wood-cula. SS 99. 
TM treailae of Dr. Maekaniia Indlapitably he 
■* - • '--e-and forma, ia toapecl of lea— ' — 



uannipiaee-aD 

mearch, as Kncyclowdia aneiiiialled iat 
any other work of Uiekliid,BiiherEngliih 01 
—bixtm an Dttfi n/tkt Eft. 



„„, „ _Baha»l«BdedeireBlalloB, 

IT ha* a prooared for their aaUianalikBamoaBtof 
Earopeu eelablily. The [mnienae reHBceh whiab 
II dlaplayed, Ibe Unroagh acqaainMnes with the 
asbjeotipraeileallyaa well aitbeuretleally, and tbe 

IIA7NE'B DIBPENSATORY AND TRERA- 
PEtJTlCAL RKMEMBRaNCKR. Wiin erorr 
PraelipBl Formnlaeiiotalnod In the three Britiih 
PharmicopiBiBa. Edited, wilh IhaaadllioDufLbe 
rotmnlie of the U. S. PJiarnucopsia, by R. B. 
U.O 1 llmo.vol.ei.el.,3Wlpp.»o. 



able raannet la which theaathor'i itarEaof iHralH 
and eiperienee were rendered imlablafor ^MMnl 
ue, at once pcocnreil for theBritedlllnn, aa well DB 
(be eonUneDl aa in Ihii coBMry, that bif\ poaiti. 

baa Don firmly aaUbliahed. We oon 

and the welbre «f bin patient at haul, ti 
■slf famllim with thia Ihe noil cuBpli 
the Engliib laDKBueapua thediieuei 
—KU. TitmtaiutOmtu. 

MALOAIGNE'S OPERATIVG SVBORRT. 

OB Normal and P>lb»l-«jcal ADat<H». 



■cly lix hunilied pagoi 






[ 

I 



AND SCIENTIFIC P ITBLIC ATI ON8. 



M 



MILLEH (JAMES), F. A. S. E., 
ProreiKii uf Surgi-ry in tK« UDiveriitYof Edioburgb, &I. 

PBtNOIPLES OF SURGERr. Fourth American, from tho third and revised 

Edinburgh edilioo. In ons lartre and very heBOtitul volume, loailieT, of TOO pu^s, wilh [vro 

huiidnid and forty illu>1r>lionii on wood. S3 TS. 

Tk« wurli or Mr. M1IJ« ■■ ton wrll anil (do fafor- 1 The wmrk Itkn nnk villi Wal>na>i Pnetl« of 
■blytBowii *BHnicH,aaDBei>f nBtheiiHsit-booka, { Pfeyalei il saruialf dMa nnl Tall bahtud thai (treat 
lu mdeiaay furthei ouCicc ufil necsmiry than Ike i iFurk ia •ouBdpsMaf ptiBelple urilonlh o( laaioD- 
annuaacemrnl of a new ediciun, lUe /iiiTlt Id uur | Idk and rewniick. No phraieiM wka valuei hiirtt- 

■a, AtaandciaaaadfallabkupDiiIiiinur IheHl^ jacquilhlinHirbBrarekiaQnd and tbe world willinut 
ancenf mntern largorr, jtalaadidsirnredl)' kink— I naklBKblmKir ramlllar with the niund aad phllo- 



Foarth AmcriciLn Irom the Inst Edis- 

ilor. Illaalraled by three hundred and ^ixtjr-four 

luiue, Jealher, o( nearly 100 pages. S3 75. 

niolry aaifery knvabfanaMitnrd iheliiihrm raak. Ifwa 

—■■— ' — -•«! to but OM wnrfc nn ■uriery, tkat 0»9 

Millet <•,■> we retard Ituinprrlar lo all 
e,wilhanl rereieueato oclmra.— A(, tnii Mid.MdSarf. Jmrwat. 

The antbor hai in ihlaand hi»" Prloeiplea," pto- 
wotMl to the praTeaaiaa one of Ike m«l eumplsteud 
reliable iraleniB of Sargery exiani. HIa atyle of 
wrlliiK la original , ImpreaaiTe, and sniaf iD(, ener- 
gutle, eoaolae, aad Inaid. Pew kave Iha famlty of 

timeeaperilitenllrhnldiBglbeBltnillon. Wkalker 

f 'rVr«V*tiISirri.'i"'nnB"l b^ '«., utZtlf ^^ 
mended^fieaftin. Jeantal ^ jtftd. mhA Pktlit*i 



ofMlller'iBurfeiT, Ita rvpuUUi 



i\j tin 



[•Prinpiple." 



and Ike " PnlMi™" of 8«r<«ry ky 
ao riihly nerllcd Ike rcpalallon they 
..«.. Tke aiilkuT U an eninenlly leDaf- 

•ataikir «i 






MORLANO (W. W.l, M. D., 

Fellow of the MaiuekuietU Uedienl Society, ft< 

■. DISKASES OF THE URINARY ORGANS; a Compendi 

PaihoUiry, and Trealtnenl. With illnHlratiung. In uoe large 
abouieoilpagra.exinidoih. iJtui btiud.) $3 30. 



D of their Diagnosis, 



I 



Itootr— Bril. and F<iT. Mid.-CAir. Km., Aprtl.iesa. Baoh auhjeet li frealed wit^ ■DKcienlminuteMie, 

dl»«»«*to'»Dleh lWi"lre>llae'rc'lalti rau'il*k»v« P'"" '" "" lii5Ti<-al degree UMful to [be (eBeral 
X;!T,^."-rTrre.rSil'ne^L"w.at";r™ol" prBetltl™er.-J^y./.-™,,/»r'd.-.4«. 
yat coneiaa rieent compuDilittm to whioh he eoutd I 

Bt MB SAME JIITTBOB -<iV™ lUaJy.) 

Tkr morbid effects of the retention in toe blood op 

THE ELEMENTS OF THE URINABV SECRETION. BoingiheDiwerlaiiun lu wUieh ihe 
Fi»ko Fund Prue wai awurded, July II, ISGl. lu one small ociavo volume, 63 pa^a, extra 
dulb. 15centa. 

MONTGOMERY (W. F.>, M. D., M. R. I. A., *c., 

Profeaanr iif Midwifery in liie Kinn.nd qgnn' a College of PliyaiciiuialB Ireland, &0. - 

AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREGNANCY. 

Wiih iiDDie other FsperB on Subject! cooneeied with Midwifery, From [ha >ea>nd atid enlarged 
Elnglixta edilinn. Wilh two eiiiuieile colored plate*, and nutneron* wood-cutn. In one very 
handiwineoeiuvo volume, eilnclulb, of nearly 600 pagea. {Latil, PiMi,h*d.) S3 19. 

rupl, every onenf then., to the | „ii^7Ji„, „,[, „ of^u oikera flieSook of 

bbatetrie Law, on each of ila aareral loplct ; ob all 

poiBta ROBneoted wilk presuncy, to be everywhere 

p.[eDt..reall imud w,th u el.^nee of dieiion, roeeived a. a maaaal of apeeUI iun.prudenee, al 

(aloe.aotiMe.lrat.on.,aeuleoeai?nd jniliK of ^r«^ ;«""■«»;■■* '"'.■'"'J'''S«'S"m 

1^?fi:e"'Thl'"r^'eV;'Vor:i^" «TV.t« I ™ 









MOHR (FRANCIS), PH. D., AND REDWOOD (TH EOPH I LUS). 
PRACTICAL PHARMAOT. Comprising the ArraDgementa, Apparatus, uid 

Manipulalioneof the FhormeoeulieaJ Shop and Lttboraiory. Edited, wilh extensive Additions, 



Iiy Fruf. Wiuj^K PxaciKS, 



iilieaJ Shop an 
<I the Phibikl 



ilphia College uf Fhurmucy. In one bvuilMimeij 



■ 



BIiANCHARD A LEA'S MEDICAL 



NEILL (JOHN), M. D., 



SH. O., 



M 

BRAHOBR < 



Profeiior uf iDiUIuUa a( Medicine in tho PfUMylvmiift Mcdiiwl CtlUef^. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANOfflB 

OF MEDICAL SCIENCE; forlhe Ura nod ExamiaBtion ol Slnileno, A new edit i 
nnd improved. Id «ie very Urge sad huid»i>mEly primed royal ISmo. voluine. « 
Ihouiwnd pages, with 374 wood-culs. BlroOKly bouad io lealher, wilh raised bando. 
Thd very flBltpring reception which hu been BcDorded lo Ibis work, Bud Ibe ttigtt e 



ilby tl 



I Iwo large edilion*, have alimulal 



kieh hag al 



rw'at 



additions wers neeeerary lo mainlniD il on a l( 
TbenleadedNrieaofJlliutrelion* has been 

Hi oftho page,lhese vaiioiUMldili 



*3vy 

laf BTcnrdingly been tborauebly eunUtd. 
TTniion have lieen eorreoled, and vkumr 
e advanne of scienpe have be«n iniroduced. 
r ioereared and mucli itnpioVBd. wbde. br 
bare been mcorporiLled witJitiut mcwiln 



Ihe Gult or lbs volume. 

The work i*,lhererora, again presenledageminentlyworlhy of IbeCavur with which it hiL-> hithem 
been received, A« a boobfor daily reftrence by the sludeal reijuiringa guide lo bis mure etalKlM 
lexl-booka, as a manual Tor preceplorr desiring to siimiilate Iheir studenl* by frequeni sad Brnuaa 
ezamiDBlion. or a« a source from whicb tbs pracltlionere o( older diiie may easily ajid cliMply ae^oai 
wiedee or the chuigei and iinpruvsmeat la prolosnioaaJ icience, its repuiaiiou i* periuaacnllT 



Tlie beat work ot thi 

BequBinted^Jirid. £zar 

HtvlBg made free lu 



lad wilh whlnh we 



for (CndFiiu, and ai eipenlally lurnl la precfpion 

■raoh labor tyeaiibltnc Ma ready)* UismII all of 
the pMnta apiM wbloh hia pupili aktMid be ax- 
amlned. A work oT thieaorlihoatd bain the ^Hiiida 
of every tne whotakBi papiliidtihlaoffloe with ■ 



Ii heavy,* 



ir all b 



> the etndeBt 
D wjioDi we very iinaerely eontmi 
a wortk lie waigbt la d 1 va